Post-stroke angiotensin II type 2 receptor activation provides long-term neuroprotection in aged rats

Activation of the angiotensin II type 2 receptor (AT2R) by administration of Compound 21 (C21), a selective AT2R agonist, induces neuroprotection in models of ischemic stroke in young adult animals. The mechanisms of this neuroprotective action are varied, and may include direct and indirect effects of AT2R activation. Our objectives were to assess the long-term protective effects of post-stroke C21 treatments in a clinically-relevant model of stroke in aged rats and to characterize the cellular localization of AT2Rs in the mouse brain of transgenic reporter mice following stroke. Intraperitoneal injections of C21 (0.03mg/kg) after ischemic stroke induced by transient monofilament middle cerebral artery occlusion resulted in protective effects that were sustained for up to at least 3-weeks post-stroke. These included improved neurological function across multiple assessments and a significant reduction in infarct volume as assessed by magnetic resonance imaging. We also found AT2R expression to be on neurons, not astrocytes or microglia, in normal female and male mouse brains. Stroke did not induce altered cellular localization of AT2R when assessed at 7 and 14 days post-stroke. These findings demonstrate that the neuroprotection previously characterized only during earlier time points using stroke models in young animals is sustained long-term in aged rats, implying even greater clinical relevance for the study of AT2R agonists for the acute treatment of ischemic stroke in human disease. Further, it appears that this sustained neuroprotection is likely due to a mix of both direct and indirect effects stemming from selective activation of AT2Rs on neurons or other cells besides astrocytes and microglia.

Sustained Neurological Recovery After Stroke in Aged Rats Treated With a Novel Prostacyclin Analog

BACKGROUND AND PURPOSE

Targeting the prostaglandin I₂ prostanoid (IP) receptor to reduce stroke injury has been hindered by the lack of selective drugs. MRE-269 is the active metabolite of selexipag showing a high selectivity toward the IP receptor. Selexipag has been recently approved for clinical use in pulmonary hypertension. We hypothesized that postischemic treatment with MRE-269 provides long-lasting neuroprotection with improved neurological outcomes in a clinically relevant rat stroke model.

METHODS

Aged male Sprague-Dawley rats underwent transient middle cerebral artery occlusion and were randomly selected to receive either vehicle or MRE-269 (0.25 mg/kg) intravenously starting at 4.5 hours post ischemia. Accelerating rotarod and adhesive removal tests were conducted before and at 3, 7, 14, and 21 days after stroke. Infarct volume was quantified by magnetic resonance imaging at 48 hours and 21 days post middle cerebral artery occlusion. In parallel experiments, cerebral cortex samples from stroke and nonstroke sides from vehicle- and MRE-269-treated groups were collected at 18 hours post middle cerebral artery occlusion for molecular biology analyses.

RESULTS

Quantitative magnetic resonance imaging data showed that postischemic MRE-269 treatment significantly reduced infarct volume compared with vehicle-treated rats at both 48 hours and 3 weeks after stroke. MRE-269 treatment resulted in a significant long-term recovery in both locomotor and somatosensory functions after middle cerebral artery occlusion, which was associated with a reduced weight loss in animals receiving the IP receptor agonist. Postischemic MRE-269 treatment reduced proinflammatory cytokines/chemokines and oxidative stress. Damage to the blood-brain barrier, as assessed by extravasation of immunoglobulin G to the ischemic brain, was significantly reduced by MRE-269, which was associated with a reduction in matrix metalloproteinase-9 activity in the brain of stroked aged rats given the IP agonist at 4.5 hours after ischemia onset.

CONCLUSIONS

Our data suggest that targeting the IP receptor with MRE-269 is a novel strategy to reduce cerebral ischemia injury and promote long-term neurological recovery in ischemic stroke.

Targeting resolution of neuroinflammation after ischemic stroke with a lipoxin A4 analog: Protective mechanisms and long-term effects on neurological recovery

BACKGROUND

Resolution of inflammation is an emerging new strategy to reduce damage following ischemic stroke. Lipoxin A₄ (LXA ₄) is an anti-inflammatory, pro-resolution lipid mediator that reduces neuroinflammation in stroke. Since LXA ₄ is rapidly inactivated, potent analogs have been synthesized, including BML-111. We hypothesized that post-ischemic, intravenous treatment with BML-111 for 1 week would provide neuroprotection and reduce neurobehavioral deficits at 4 weeks after ischemic stroke in rats. Additionally, we investigated the potential protective mechanisms of BML-111 on the post-stroke molecular and cellular profile.

METHODS

A total of 133 male Sprague-Dawley rats were subjected to 90 min of transient middle cerebral artery occlusion (MCAO) and BML-111 administration was started at the time of reperfusion. Two methods of week-long BML-111 intravenous administration were tested: continuous infusion via ALZET ^® osmotic pumps (1.25 and 3.75 μg μl^-1 hr^-1), or freshly prepared daily single injections (0.3, 1, and 3 mg/kg). We report for the first time on the stability of BML-111 and characterized an optimal dose and a dosing schedule for the administration of BML-111.

RESULTS

One week of BML-111 intravenous injections did not reduce infarct size or improve behavioral deficits 4 weeks after ischemic stroke. However, post-ischemic treatment with BML-111 did elicit early protective effects as demonstrated by a significant reduction in infarct volume and improved sensorimotor function at 1 week after stroke. This protection was associated with reduced pro-inflammatory cytokine and chemokine levels, decreased M1 CD40+ macrophages, and increased alternatively activated, anti-inflammatory M2 microglia/macrophage cell populations in the post-ischemic brain.

CONCLUSION

These data suggest that targeting the endogenous LXA ₄ pathway could be a promising therapeutic strategy for the treatment of ischemic stroke. More work is necessary to determine whether a different dosing regimen or more stable LXA ₄ analogs could confer long-term protection.

A critical role for the melanocortin 4 receptor in stress-induced relapse to nicotine seeking in rats

Tobacco addiction is characterized by a lack of control over smoking and relapse after periods of abstinence. Smoking cessation leads to a dysphoric state that contributes to relapse to smoking. After the acute withdrawal phase, exposure to stressors increases the risk for relapse. Blockade of melanocortin 4 (MC4 ) receptors has anxiolytic and antidepressant-like effects in animal models. The aim of these studies was to investigate the role of MC4 receptors in the dysphoria associated with nicotine withdrawal and stress-induced reinstatement of nicotine seeking. To study stress-induced reinstatement, rats self-administered nicotine for 16 days and then nicotine seeking was extinguished by substituting saline for nicotine. Nicotine seeking was reinstated by intermittent footshock stress. The intracranial self-stimulation (ICSS) procedure was used to assess the negative mood state associated with nicotine withdrawal. Elevations in the ICSS thresholds are indicative of a dysphoric state. The selective MC4 receptor antagonists HS014 and HS024 prevented stress-induced reinstatement of extinguished nicotine seeking. Drug doses that prevented stress-induced relapse did not affect responding for food pellets, which indicates that the drugs did not induce sedation or motor impairments. In the ICSS experiments, the nicotinic acetylcholine receptor antagonist mecamylamine elevated the ICSS thresholds of the nicotine-dependent rats. Pre-treatment with HS014 or HS024 did not prevent the elevations in ICSS thresholds. These studies indicate that MC4 receptors play a critical role in stress-induced reinstatement of nicotine seeking, but these receptors may not play a role in the dysphoria associated with acute nicotine withdrawal.

Abstract W MP85: Prostacyclin Receptor Activation With MRE-269 Reduces Infarct Size and Improves Long-term Neurological Recovery Following Ischemic Stroke in Both Young and Aged Rats

Activation of the prostacyclin (PGI2) IP receptor is protective in brain ischemia. However, there is very limited information of the molecular mechanisms of protection and the feasibility to target this pathway in stroke. MRE-269, a highly selective PGI2/IP receptor agonist, has been recently discovered. This IP agonist has a long half-life in vivo and is currently in phase III clinical trials for pulmonary hypertension. We hypothesized that post-ischemic treatment with MRE-269 provides neuroprotection in a rat ischemic stroke model. Young male rats (3-4-month old) were subjected to middle cerebral artery occlusion (MCAO) for 90 min and treated intravenously with either vehicle (n=14) or MRE-269 (0.1, 0.25, 0.5, and 1 mg/kg, n=10-14/group) at the start of reperfusion. At 48 h post-MCAO, rats were sacrificed to determine infarct size, blood-brain barrier (BBB) damage (IgG extravasation), hemorrhagic transformation (brain hemoglobin levels), and matrix metalloproteinase (MMP)-9 activity. In a separate experiment, aged male rats (18-20-month old) underwent 90 min of MCAO and randomly selected to receive intravenously either vehicle (n=11) or MRE-269 (0.25 mg/kg, n=11) starting at 4.5 h post-MCAO. Additional doses were given every 12 h for the first 48 h, and then one injection daily for 7 days post-MCAO. The accelerating rotarod and the adhesive removal tests were conducted before and at 3, 7, 14 and 21 days after MCAO by an investigator blinded to treatment groups. Infarct volume was quantified by MRI at 48 h and 21 days post-MCAO. In young rats, MRE-269 dose-dependently reduced cortical infarct size. MRE-269-treated rats (0.25 mg/kg) had significantly reduced BBB damage and less hemorrhagic transformation. Compared with the vehicle group, MRE-269-treated animals showed a significant reduction in brain MMP-9 activity. In aged rats, MRE-269 treatment resulted in a significant long-term recovery in both locomotor and somatosensory functions following MCAO. Quantitative MRI data showed that MRE-269 significantly reduced infarct volume compared with vehicle-treated rats. Our data suggest that targeting the PGI2/IP receptor with MRE-269 is a novel strategy to reduce neurovascular injury and promote long-term neurological recovery in ischemic stroke.

Acute nicotine administration increases BOLD fMRI signal in brain regions involved in reward signaling and compulsive drug intake in rats

BACKGROUND

Acute nicotine administration potentiates brain reward function and enhances motor and cognitive function. These studies investigated which brain areas are being activated by a wide range of doses of nicotine, and if this is diminished by pretreatment with the nonselective nicotinic receptor antagonist mecamylamine.

METHODS

Drug-induced changes in brain activity were assessed by measuring changes in the blood oxygen level dependent (BOLD) signal using an 11.1-Tesla magnetic resonance scanner. In the first experiment, nicotine naïve rats were mildly anesthetized and the effect of nicotine (0.03-0.6 mg/kg) on the BOLD signal was investigated for 10 min. In the second experiment, the effect of mecamylamine on nicotine-induced brain activity was investigated.

RESULTS

A high dose of nicotine increased the BOLD signal in brain areas implicated in reward signaling, such as the nucleus accumbens shell and the prelimbic area. Nicotine also induced a dose-dependent increase in the BOLD signal in the striato-thalamo-orbitofrontal circuit, which plays a role in compulsive drug intake, and in the insular cortex, which contributes to nicotine craving and relapse. In addition, nicotine induced a large increase in the BOLD signal in motor and somatosensory cortices. Mecamylamine alone did not affect the BOLD signal in most brain areas, but induced a negative BOLD response in cortical areas, including insular, motor, and somatosensory cortices. Pretreatment with mecamylamine completely blocked the nicotine-induced increase in the BOLD signal.

CONCLUSIONS

These studies demonstrate that acute nicotine administration activates brain areas that play a role in reward signaling, compulsive behavior, and motor and cognitive function.

Blockade of CRF1 receptors in the central nucleus of the amygdala attenuates the dysphoria associated with nicotine withdrawal in rats

The majority of smokers relapse during the acute withdrawal phase when withdrawal symptoms are most severe. The goal of the present studies was to investigate the role of corticotropin-releasing factor (CRF) and noradrenergic transmission in the central nucleus of the amygdala (CeA) in the dysphoria associated with smoking cessation. It was investigated if blockade of CRF1 receptors, blockade of α1-adrenergic receptors, or stimulation of α2-adrenergic receptors in the CeA diminishes the deficit in brain reward function associated with nicotine withdrawal in rats. Nicotine dependence was induced by implanting minipumps that delivered a nicotine solution. Withdrawal was precipitated with the nicotinic acetylcholine receptor antagonist mecamylamine. A discrete-trial intracranial self-stimulation procedure was used to assess the negative affective aspects of nicotine withdrawal. Elevations in brain reward thresholds are indicative of a deficit in brain reward function. In all the experiments, mecamylamine elevated the brain reward thresholds of the rats chronically treated with nicotine and did not affect the brain reward thresholds of the saline-treated control rats. Intra-CeA administration of the CRF1 receptor antagonist R278995/CRA0450 completely prevented the mecamylamine-induced elevations in brain reward thresholds in the nicotine-treated rats and did not affect the brain reward thresholds of the saline-treated control rats. R278995/CRA0450 has also been shown to block sigma-1 receptors but there is no evidence that this could affect negative mood states. Intra-CeA administration of the α1-adrenergic receptor antagonist prazosin or the α2-adrenergic receptor agonist clonidine did not affect the brain reward thresholds of the nicotine or saline-treated rats. These studies suggest that CRF1 receptor antagonists may diminish the dysphoria associated with smoking cessation by blocking CRF1 receptors in the CeA.

Effects of prazosin, clonidine, and propranolol on the elevations in brain reward thresholds and somatic signs associated with nicotine withdrawal in rats

RATIONALE

Tobacco withdrawal is characterized by a negative mood state and relatively mild somatic symptoms. Increased noradrenergic transmission has been reported to play an important role in opioid withdrawal, but little is known about the role of noradrenergic transmission in nicotine withdrawal.

OBJECTIVES

The aim of these experiments was to investigate the effects of prazosin, clonidine, and propranolol on the negative mood state and somatic signs associated with nicotine withdrawal in rats.

METHODS

A discrete-trial intracranial self-stimulation procedure was used to assess the negative affective state of nicotine withdrawal. Elevations in brain reward thresholds are indicative of a deficit in brain reward function.

RESULTS

In all the experiments, the nicotinic acetylcholine receptor antagonist mecamylamine (3 mg/kg) elevated the brain reward thresholds of the nicotine-treated rats and did not affect those of the control rats. The α1-adrenergic receptor antagonist prazosin (0.0625 and 0.125 mg/kg) dose-dependently attenuated the elevations in brain reward thresholds associated with precipitated nicotine withdrawal. The α2-adrenergic receptor agonist clonidine (10-40 μg/kg) and the nonselective β-adrenergic receptor antagonist propranolol (2.5-10 mg/kg) did not attenuate the elevations in brain reward thresholds associated with nicotine withdrawal. Furthermore, mecamylamine (2 mg/kg) induced more somatic signs in the nicotine-treated rats than in the control rats. Clonidine and propranolol, but not prazosin, decreased the total number of somatic signs associated with nicotine withdrawal.

CONCLUSION

Blockade of α1-adrenergic receptors attenuates the deficit in brain reward function associated with nicotine withdrawal. Antagonism of β-adrenergic receptors or stimulation of α2-adrenergic receptors attenuates the somatic symptoms of nicotine withdrawal.

The role of calsenilin/DREAM/KChIP3 in contextual fear conditioning

Potassium channel interacting proteins (KChIPs) are members of a family of calcium binding proteins that interact with Kv4 potassium (K(+)) channel primary subunits and also act as transcription factors. The Kv4 subunit is a primary K(+) channel pore-forming subunit, which contributes to the somatic and dendritic A-type currents throughout the nervous system. These A-type currents play a key role in the regulation of neuronal excitability and dendritic processing of incoming synaptic information. KChIP3 is also known as calsenilin and as the transcription factor, downstream regulatory element antagonist modulator (DREAM), which regulates a number of genes including prodynorphin. KChIP3 and Kv4 primary channel subunits are highly expressed in hippocampus, an area of the brain important for learning and memory. Through its various functions, KChIP3 may play a role in the regulation of synaptic plasticity and learning and memory. We evaluated the role of KChIP3 in a hippocampus-dependent memory task, contextual fear conditioning. Male KChIP3 knockout (KO) mice showed significantly enhanced memory 24 hours after training as measured by percent freezing. In addition, we found that membrane association and interaction with Kv4.2 of KChIP3 protein was significantly decreased and nuclear KChIP3 expression was increased six hours after the fear conditioning training paradigm with no significant change in KChIP3 mRNA. In addition, prodynorphin mRNA expression was significantly decreased six hours after fear conditioning training in wild-type (WT) but not in KO animals. These data suggest a role for regulation of gene expression by KChIP3/DREAM/calsenilin in consolidation of contextual fear conditioning memories.

Regulation of surface localization of the small conductance Ca2+-activated potassium channel, Sk2, through direct phosphorylation by cAMP-dependent protein kinase

Small conductance, Ca2+-activated voltage-independent potassium channels (SK channels) are widely expressed in diverse tissues; however, little is known about the molecular regulation of SK channel subunits. Direct alteration of ion channel subunits by kinases is a candidate mechanism for functional modulation of these channels. We find that activation of cyclic AMP-dependent protein kinase (PKA) with forskolin (50 microm) causes a dramatic decrease in surface localization of the SK2 channel subunit expressed in COS7 cells due to direct phosphorylation of the SK2 channel subunit. PKA phosphorylation studies using the intracellular domains of the SK2 channel subunit expressed as glutathione S-transferase fusion protein constructs showed that both the amino-terminal and carboxyl-terminal regions are PKA substrates in vitro. Mutational analysis identified a single PKA phosphorylation site within the amino-terminal of the SK2 subunit at serine 136. Mutagenesis and mass spectrometry studies identified four PKA phosphorylation sites: Ser465 (minor site) and three amino acid residues Ser568, Ser569, and Ser570 (major sites) within the carboxyl-terminal region. A mutated SK2 channel subunit, with the three contiguous serines mutated to alanines to block phosphorylation at these sites, shows no decrease in surface expression after PKA stimulation. Thus, our findings suggest that PKA phosphorylation of these three sites is necessary for PKA-mediated reorganization of SK2 surface expression.

Oral glycoprotein IIb/IIIa inhibition with orbofiban in patients with unstable coronary syndromes (OPUS-TIMI 16) trial

BACKGROUND

Although intravenous glycoprotein IIb/IIIa inhibitors are beneficial in patients with acute coronary syndromes, prolonged oral IIb/IIIa inhibition might provide an additional reduction in recurrent events.

METHODS AND RESULTS

Investigators at 888 hospitals in 29 countries enrolled 10 288 patients with acute coronary syndromes, which was defined as ischemic pain at rest within 72 hours of randomization, associated with positive cardiac markers, electrocardiographic changes, or prior cardiovascular disease. Patients received aspirin and were randomized to receive, for the duration of the trial, (1) 50 mg of orbofiban twice daily (50/50 group), (2) 50 mg of orbofiban twice daily for 30 days followed by 30 mg of orbofiban twice daily (50/30 group), or (3) a placebo. The primary composite end point was death, myocardial infarction, recurrent ischemia requiring rehospitalization, urgent revascularization, or stroke. The trial was terminated prematurely because of an unexpected increase in 30-day mortality in the 50/30 orbofiban group. Mortality through 10 months was 3.7% for the placebo group versus 5.1% in the 50/30 group (P=0.008) and 4.5% in the 50/50 group (P=0.11). There were no differences in the primary end point (22.9%, 23.1%, and 22.8%, for the placebo, 50/30, and 50/50 groups, respectively). Major or severe bleeding (but not intracranial hemorrhage) was higher with orbofiban; it occurred in 2. 0%, 3.7% (P=0.0004), and 4.5% (P<0.0001) of patients, respectively. Exploratory subgroup analyses found that patients who underwent percutaneous coronary intervention had a lower mortality and a significant reduction in the composite end point (P=0.001) with orbofiban.

CONCLUSIONS

-Fixed-dose orbofiban failed to reduce major cardiovascular events and was associated with increased mortality in this broad population of patients with acute coronary syndromes; however, a benefit was observed among patients who underwent percutaneous coronary intervention.

Method for creation of the aortotomy site for saphenous vein grafts

Saphenous vein coronary artery bypass grafting requires a proximal anastomosis of the vein to the aorta. A variety of techniques have been described to create the aortotomy. We have developed a four-sided knife (Xcision Scalpel; patent pending, Research Medical, Inc, Midvale, UT) that facilitates the creation of a more uniform circular aortotomy. The purpose of this communication is to describe the knife and the technique for its use.

False aneurysm of the right internal mammary artery. Late rupture after sternotomy

This report describes a late, near-fatal rupture of a false aneurysm of the right internal mammary artery subsequent to coronary artery bypass grafting. The patient presented to us in shock due to hemorrhaging, 8 weeks after bypass surgery that had been complicated by sternal fracture, dehiscence, and infection. Emergent thoracotomy and suture ligation controlled the hemorrhage. To the best of our knowledge, this is the 1st reported case of late massive hemorrhage caused by injury to an internal mammary artery after sternotomy. The literature is reviewed and discussed.

Hemodynamic stabilization of acute prosthetic valve thrombosis using percutaneous catheter manipulation

Thrombosis of a tilting-disk prosthetic heart valve can be an acute and potentially life-threatening problem. Surgical thrombectomy, valve replacement, or systemic thrombolytic agents have been successfully employed in the management of such cases. Some patients, however, may not survive the acute episode long enough to receive definitive surgical therapy. For such patients, temporary hemodynamic stabilization might be achieved by re-establishing partial valve disk mobility. This report describes a technique for re-establishing valve disk mobility in an acutely compromised patient by using a percutaneously introduced "rigid" catheter to manipulate an entrapped tilting-disk valve in the aortic position.

Modulation of alloreactivity in transplant recipients by phenotypic manipulation of donor endothelium

Phenotypic manipulation of allograft endothelium to reduce immunogenicity would have a significant impact on transplantation. In this study we have demonstrated that random seeding of a heart allograft with endothelium, of host origin, not only promotes long-term survival, but reduces the requirement for pharmacologic immunosuppression. We propose that this simple technology could easily be extrapolated to the clinical arena where hypothermia and preservation solutions have allowed allografts to remain ex vivo for extended periods.

The relationship between hospital charges and a modified Parsonnet risk score

Health care now consumes approximately 14 percent of the U.S. Gross National Product (GNP). The amount of money spent on health care in America per capita and as a percentage of GNP far exceeds that of any other industrialized country. Currently, the financial burden of health care is being shouldered by government and business. The expenditure of billions of dollars of corporate profits on health care progressively undermines the global competitiveness of American business. These economic realities have emerged as the dominant driving force in health care reform. Cost control efforts to date have focused on strategies to limit inpatient hospital expenditures. The DRG prospective payment system is designed to reimburse a fixed sum based on the diagnostic category of the patient. The DRG payment is essentially independent of underlying patient characteristics that can potentially drive up expenditures. The work reported in this article was done to develop a descriptive formula that could be used to predict resource consumption in the care of patients. The financial viability of a hospital depends on its ability to predict expenditures, allocate resources, and choose its service areas correctly. Errors in financial forecasting in the era of prospective payment will result in financial failures of entire institutions.

The haemostatic effectiveness of autologous platelet rich plasma sequestered after heparin administration and institution of cardiopulmonary bypass

Preoperative harvesting and postoperative reinfusion of autologous platelet rich plasma (PRP) has been reported to decrease blood loss as well as the requirement for homologous blood transfusion following cardiopulmonary bypass (CPB). We have developed a technique of intraoperative PRP sequestration which occurs during the initial period of CPB after the patient's circulation is supported and heparin has been given (PRP+). This process does not require any additional hardware, personnel or expense and it is performed without difficulty or complication. To evaluate the effect of PRP+ sequestration and reinfusion on blood loss and homologous blood requirement after CPB, we randomly assigned 126 consecutive patients undergoing elective open heart surgery into the experimental group 1 (PRP+) (n = 64) or the control (no platelet pheresis) group 2 (n = 52). A third group (n = 10) were not included in the randomization. Patients in group 3 had PRP prepared by conventional techniques (PRPc) prior to heparin administration and given to the patient after protamine infusion. Aggregation and activation studies were performed on the PRP+, PRPc, and blood bank platelets (BBP). Per cent aggregation of PRP in response to ADP was superior to that of BBP. There were no significant differences in ADP induced aggregation between PRP+ and PEPc. There was no significant difference in platelet activation (CD62) or number between the three groups. Patients infused with PRP+ showed significantly increased aggregation to ADP when compared with untreated patients 120 minutes after return to the ICW. Furthermore, more homologous haemostatic components (platelets/fresh frozen plasma) were required in the control group. We have demonstrated that collection of autologous PRP+ after administration of heparin does not interfere with its haemostatic effectiveness compared with PRPc prepared before the initiation of bypass. Moreover, this can be performed universally in haemodynamically unstable patients without any additional costs.

Cardiopulmonary bypass with adequate flow and perfusion pressures prevents endotoxaemia and pathologic cytokine production

Endotoxin and cytokine inflammatory mediators comprise the afferent and efferent limbs of the 'acute phase response'. During cardiopulmonary bypass (CPB) there may be gut translocation of endotoxin and contact activation of lymphocytes. It has been hypothesized that the haemodynamic instability encountered following CPB is caused by the 'acute phase response'. In this study we attempted to quantify the acute phase response in patients undergoing open-heart surgery and determine the influence of these cytokines on perioperative morbidity. Four perioperative blood samples were drawn from 20 consecutive patients undergoing coronary artery bypass grafting (CABG). These samples were assayed for endotoxin and four cytokines. In all cases the cardiac index was maintained > 2.4 l/min/m2 during nonpulsatile normothermic bypass (37 degrees C) and > 1.8 l/min/m2 during nonpulsatile hypothermic bypass (28 degrees C), and the perfusion pressure > 60 mmHg. Endotoxin was not detected in any of the test samples despite positive nonpatient controls. Interleukin 6 (IL-6) and tumour necrosis factor (TNF) were not detected despite an assay sensitivity of 80 and 10 pg/ml, respectively. TNF was detectable with an assay sensitivity of 0.5 pg/ml although there were no significant differences within the group. Interleukin 1 (IL-1) was detected (range = 0.98 - 9.09 ng/ml) in patients and again there were no trends within the group. The platelet activating factor (PAF) values peaked at crossclamp release (1.3 ng/ml versus a baseline of 0.2 ng/ml); however, there was no significant difference within the study.

Management of massive pulmonary thromboembolism complicating diabetic ketoacidosis

Intravascular volume depletion secondary to diabetic ketoacidosis may result in thrombosis of major blood vessels. Without anticoagulation these thrombi can embolize to the lungs and compromise cardiopulmonary function. When this occurs early surgical pulmonary embolectomy is indicated to salvage a failing right heart.

Intraoperative procurement of autologous fibrin glue

A method of intraoperative procurement of autologous fibrin glue is described. The relative efficacy of our autologous preparation is compared with that of fibrin glue made with homologous cryoprecipitate. Experimentally, the fibrinogen content and the strength are less than those found in cryoprecipitate and appear related to the fibrinogen content of the autologous plasma used as substrate in the fibrin glue reaction. Clinically, no significant differences are noted in the performance of autologous fibrin glue. We believe the absence of the risk of blood-borne infection with the autologous product is a major advantage.

On the dynamics of bursting systems

The dynamics of three-variable models of bursting are studied. It is shown that under certain conditions, the dynamics on the attractor can be essentially reduced to two dimensions. The salient dynamics on the attractor can thus be completely described by the return map of a section which is a logistic interval map. Two specific bursting models from the literature are shown to fit in the general framework which is developed. Bifurcation of the full system for one case in investigated and the dynamical behavior on the attractor is shown to depend on the position of a certain nullcline.

Right lower lobectomy for pulmonary infarction before orthotopic heart transplantation

A 39-year-old potential heart transplant recipient had a right lower lobe infiltrate and on pulmonary angiography was found to have an embolous to the common basilar artery. This was successfully managed by a right lower lobectomy, after aggressive medical management failed. The patient was treated postoperatively with antibiotics and subsequently underwent orthotopic heart transplantation. At 1 year after transplant the patient has no evidence of cardiac or pulmonary insufficiency.

Decreased platelet number and function and increased fibrinolysis contribute to postoperative bleeding in cardiopulmonary bypass patients

We simultaneously evaluated platelet and fibrinolytic parameters to assess their individual and combined contributions to postoperative blood loss in cardiopulmonary (CP) bypass patients. Platelet count, platelet aggregability, hematocrit, plasminogen (PLG) concentration, alpha 2-antiplasmin (AP) concentration, free protease activity (fPA), and antithrombin-III (AT-III) were measured in nine patients undergoing surgery using cardiopulmonary bypass. Chest tube drainage was used as the measure of postoperative blood loss. Hematocrit, platelet count, PLG, AP, and AT-III all decreased during CP bypass, with PLG and AT-III decreasing much more than dilution. During CP bypass, platelet aggregability to ADP did not change significantly from pre-bypass, but aggregability to arachidonic acid (AA) decreased significantly. Following protamine administration there was a large increase (83%) in fPA, the platelet count showed a further drop (from 61% to 50% of pre-bypass levels), and platelet aggregability decreased significantly (from 95% to 34% of pre-bypass levels for ADP, and from 55% to 11.9% for AA). Chest tube drainage during the first four postoperative hours correlated positively (p less than 0.05) with the combination of increase in free protease activity and decrease in platelet count. The total chest tube drainage correlated significantly with the combination of decrease in platelet count and the decrease in platelet aggregability. These combinations of changes correlated significantly with postoperative blood loss whereas the individual changes did not.(ABSTRACT TRUNCATED AT 250 WORDS)

Biological observations from feeding heated corn oil and heated peanut oil to rats

Five groups of male weanling rats were provided purified diets containing 15% by weight of either fresh or laboratory-heated corn oil (FCO, HCO) or fresh, laboratory-heated, or commercial pressure deep-fry peanut oil (FPO, HPO, PPO). Total weight gain, feed consumption, and feed efficiency were consistently greater for the FCO, FPO, and PPO groups. Although relative heart weights were unaffected, the HCO and HPO produced elevated liver and kidney weights. The dietary fats had no effect on the hematological status of the animals or the proportions of cells comprising the total leukocytes of the blood. Physical, chemical, and microscopic evaluation of the urine detected no pathologic conditions. Rats fed diets containing HCO or HPO demonstrated toxicity of thermally oxidized fats by the appearance of diarrhea, dermatitis, seborrhea, and hair loss. Histological examinations revealed injury of the thymus by all fat samples except the FCO; the liver was damaged by the HCO, HPO, and PPO, and the testes and epididymides by HPO and PPO. In the latter case there was complete cessation of spermatogenesis.

Calcium-accentuated ischemic damage during reperfusion: the time course of the reperfusion injury in the isolated working rat heart model

The purpose of this study was to determine the time course of calcium-induced postischemic reperfusion injury to the myocardium, using an initial short-term calcium-enriched reperfusion solution. The isolated rat heart model was subjected to 30 min of normothermic potassium cardioplegia-induced ischemic arrest. Control hearts received normal calcium Krebs-Henseliet buffer (KHB) reperfusion. Experimental hearts were challenged with 10 min of calcium-enriched (KHB) reperfusion starting at 0, 1, 2, 5, 15, and 30 min after the beginning of reperfusion. Aortic flow recovery 60 min after reperfusion was used to determine functional recovery. Control hearts recovered 82 +/- 3% of preischemic aortic flow. Hearts which received calcium challenge at 0 and 1 min after the start of reperfusion recovered 43 +/- 4 and 69 +/- 3% of preischemic aortic flow, respectively (P less than 0.01 and P less than 0.05, respectively). Hearts which received calcium challenge 2, 5, 15, and 30 min after reperfusion recovered 75 +/- 2, 80 +/- 2, 85 +/- 2, and 83 +/- 2% of preischemic aortic flow, respectively. Our results indicate that the postischemic myocardium is very susceptible to calcium-accentuated ischemic damage during the initial period of reperfusion. The postischemic heart, however, quickly recovers its ability to withstand a calcium challenge. Five minutes after the start of reperfusion the heart is not influenced by calcium challenge.

Spontaneous oscillations in two 2-component cells coupled by diffusion

Mathematical examples are presented of oscillators with two variables which do not oscillate in isolation, but which do oscillate stably when coupled with a twin via diffusion. Two examples are presented, the Lefever-Prigogine Brusselator and a system used to model glycolytic oscillations. The mathematical method is not the usual bifurcation theory, but rather a type of singular perturbation theory combined with bifurcation theory. For both examples, it is shown that all stationary solutions are unstable for appropriate parameter settings. In the case of the Brusselator, it is further shown that there exist limit cycles; i.e. stable oscillations, in this parameter range. A numerical example is presented.

Terminal magnesium cardioplegia: protective effect in the isolated rat heart model using calcium accentuated ischemic damage

We have developed a modified isolated working rat heart model to study the effect of potassium and magnesium cardioplegia given just prior to reperfusion, "terminal cardioplegia," on preservation of aortic flow following a standard ischemic insult. The model incorporates a short-term calcium challenge at the beginning of reperfusion to accentuate ischemic injury. All hearts were given initial potassium cardioplegia and subjected to 30 min of normothermic ischemia. Terminal cardioplegia was given for the 2 min prior to reperfusion. Calcium-challenged hearts were reperfused initially with calcium-enriched reperfusate and then switched to standard reperfusate. Aortic flow prior to and 60 min after ischemia was used to determine functional protection. Hearts recovered 82 +/- 3% of preischemic aortic flow when reperfused with normocalcemic reperfusate. When the initial reperfusate was enriched with calcium, aortic flow was only 43 +/- 4% of control. Hearts given terminal magnesium cardioplegia and then challenged with calcium-enriched reperfusate recovered 79 +/- 4% of control aortic flow. Hearts given terminal potassium cardioplegia recovered only 53 +/- 5% of control aortic flow when challenged with calcium-enriched initial reperfusate. Our results indicate that the recovery of aortic flow is significantly reduced by short-term postischemic calcium challenge. This damage is blocked by terminal magnesium cardioplegia, but not by terminal potassium cardioplegia.

Chylothorax review

Chylous leakage from the thoracic duct into the pleural space may occur after any type of thoracic surgery; however, there are few reports of this condition after coronary artery bypass grafting. A case of chylothorax after combined coronary bypass and mitral valve replacement is reported to illustrate a discussion of its pathologic basis, diagnosis and management.

Long-term experience with nadolol in treatment of hypertension and angina pectoris

Two-hundred ninety-one patients with hypertension and 313 patients with angina pectoris were enrolled and treated with nadolol for up to 2 years. The efficacy of nadolol in hypertension and angina was maintained over the 2-year period. Discontinuation because of an adverse reaction occurred with 8.3% of the hypertensive patients and 8.6% of the angina patients. The observed reactions were typical of those which occur with beta-blocking drugs. Serum creatinine levels fell significantly (p less than 0.05) after 12 months of treatment for both the angina and hypertensive patients. After 24 months of treatment the serum creatinine levels had decreased 20% from baseline (p less than 0.001). Blood urea nitrogen levels fell in the angina patients after 12 months of treatment but not in the hypertensive patients. Nadolol is safe and effective for the long-term treatment of both hypertension and angina. Renal function, as measured by serum creatinine levels, improved with long-term treatment.

Inhibition of chemiluminescence in human neutrophils by dapsone

Dapsone at doses of 0.5 to 5.0 micrograms/ml was found to produce a dose-dependent inhibition of opsonized zymosan-induced human polymorphonuclear leukocyte (PMN) chemiluminescence (CL) in vitro. Simultaneous exposure of PMN to dapsone and zymosan was as effective in reducing CL as preincubation of PMN with dapsone. Preincubation of PMN with dapsone followed by washing, resulted in the loss of dapsone-mediated CL inhibition, indicating that dapsone did not permanently alter the CL-generating mechanism and that the drug had to be present to inhibit CL. Dapsone did not absorb light at the wavelength of CL and was not toxic to PMN at concentrations tested. Sodium azide, an inhibitor of myeloperoxidase-mediated CL inhibited PMN CL to the same degree as dapsone. When incubated together with PMN, dapsone and azide did not produce an additive inhibition of CL. These data suggest that inhibition of myeloperoxidase may be the mechanism by which dapsone inhibits PMN CL.

Captopril in the treatment of scleroderma renal crisis

Scleroderma is a disease of unknown cause characterized by interstitial fibrosis and vascular lesions in many organ systems. Renal failure, often associated with malignant hypertension, may ensue as a life-threatening component of this disorder. Activation of the renin-angiotensin-aldosterone system has been hypothesized as a cause of this complication. Captopril has been used in 23 patients with this condition. Of this group, 20 (87%) responded favorably with a decrease of the supine diastolic BP to less than 90 mm Hg and a reduction in the serum creatinine level in 14 patients. During long-term therapy (median, 29 months), 11 of the 23 patients continued to have a good clinical response while receiving captopril. Six patients died and six patients were alive after captopril therapy was discontinued. These data suggest that captopril is beneficial in the treatment of scleroderma renal crisis.

Stapled esophagogastric anastomosis

In a consecutive, nonrandomized series of 92 patients, esophagogastric anastomosis was performed with a suture technique in 32 patients and with a stapler in 60 patients. Only one anastomotic leak occurred in each group. Stricture later formed in three sutured anastomoses and in eight of the stapled anastomoses. A review of published reports shows anastomotic leak in 3.5 percent of the patients with stapled anastomoses. In patients with sutured anastomoses, leak occurred in approximately 10 percent. The improved results with the stapler do not alter the necessity for meticulous attention to technical detail.

Enzymatic hydrolysis in vitro of thermally oxidized sunflower oil

The hydrolysis of thermally oxidized sunflower oil by pancreatic lipase was studied in relation to chemical changes in the acylglycerols. Four classes of compounds (monomers, dimers, trimers and polymers) formed from the acylglycerols were separated from the heated oils by column chromatography on silica gel, and further verified by thin layer chromatography. Each fraction, after analyses for generaly properties, was subjected to a time course study of hydrolysis by pancreatic lipase over a 30-min period. After 70 hr of heating, the amount of hydrolysis for the acylglycerol dimers was only about half that of the monomers, and that for the trimers was, in turn, about one-third that of the monomers. The polymers were the least hydrolyzed and showed no further reaction after 5 min. The reduction in enzymatic hydrolysis of isolated fractions from the thermally oxidized oils indicates structural differences, related to formation of polar compounds and polymerization products. Adverse effects on animals from feeding these materials can be attributed partly to inhibition of hydrolysis resulting in less available energy.

Enzymatic hydrolysis of fractionated products from oils thermally oxidized in the laboratory

Enzymatic hydrolysis of the acylglycerol products obtained from thermally oxidized vegetable oils was studied. Corn, sunflower and soybean oils were heated in the laboratory at 180 C for 50, 70 and 100 hr with aeration and directly fractionated by silicic acid column chromatography. By successive elution with 20%, then 60% isopropyl ether in n-hexane, and diethyl ether, the thermally oxidized oils were separated into three fractions: the nonpolar fraction (monomeric compounds), slightly polar fraction (dimeric compounds), and polar fraction comprising oligomeric compounds. Enzymatic hydrolysis with pancreatic lipase showed that the monomers were hydrolyzed as rapidly as the corresponding unheated oils, the dimers much more slowly, and the oligomeric compounds barely at all. Overall, the hydrolysis of the dimers was less than 23% of that for the monomers, with small differences among the oils. Longer heating periods resulted in greater reductions in hydrolysis of the dimeric compounds. These results suggest that the degree of enzymatic hydrolysis of the fractionated acylglycerol compounds is related to differences in the thermal oxidative deterioration, and amounts of polar compounds in the products.

Dysrhythmias caused by histamine release in guinea pig and human hearts

Histamine is released into the systemic circulation during anaphylaxis, by drugs and by surgical procedures. Studies in animal models have conclusively demonstrated that released cardiac histamine is a major mediator of arrhythmias that occur during anaphylaxis and following the administration of histamine-releasing drugs. Several lines of evidence suggest a similar arrhythmogenic role for cardiac histamine in humans: (1) The human heart is rich in histamine; (2) cardiac histamine can be readily released from human heart in vitro by therapeutic concentrations of drugs; (3) histamine has potent arrhythmogenic effects on the human heart in vitro. Arrhythmogenic effects of histamine include enhancement of normal automaticity, induction of abnormal automaticity, induction of triggered tachyarrhythmias, depression of atrioventricular conduction, and increase in the vulnerability of the ventricles to fibrillation. A combination of H1 and H2 antihistamines is needed to block the arrhythmogenic effects of histamine. Certain arrhythmogenic effects of histamine (e.g. induction of slow responses and delayed afterdepolarizations) can also be blocked by drugs which inhibit the influx of cations through slow channels. In contrast, the commonly-used drug digitalis potentiates the arrhythmogenic effects of histamine. We propose that histamine release produced by drugs and surgical procedures may be an overlooked factor in fatal cardiac arrhythmias. Experimental studies suggest that selective pharmacological methods can be developed to block the arrhythmogenic effects of histamine.

Influence of dose level and methionine intake on the effects of linamarin administration to rats

Rats were fed a semipurified diet providing 10% casein supplemented with methionine for 2 wk, at which time some animals received the same diet without the methionine for 4 d. Animals that received linamarin were given a single oral dose containing 500 or 250 mg per kilogram of body weight. At the higher linamarin dose all animals died within 5 h after dosing. Biochemical and physiological changes observed in these rats included severe metabolic acidosis, decreased cytochrome oxidase activities, atrial fibrillation, and decreased respiratory rates. In general, the cardiac adenosinetriphosphatase enzymes were inhibited by linamarin. None of these changes were moderated by dietary methionine supplementation. At the lower linamarin dose dietary supplementation with methionine appeared to reduce incidences of clinical toxicity signs and fatalities. No methionine effect was observed in the other biochemical and physiological measurements in rats given this amount of linamarin. The results suggest that dietary supplementation with methionine provided some protection against the toxicity of the lower level of linamarin administered.

Cytotoxicity of thermally oxidized fats

The effects of oxidized fat components (free fatty acids from the distillable nonurea adductable fraction) isolated from heated corn oil or heated olive oil on the morphology and growth of heart cells in primary culture were investigated. The free fatty acid fractions isolated from the fresh fats served as controls. Different concentrations of the fat fractions (20, 60, and 100 micrograms/ml) were added to the medium in the form of an emulsion with bovine serum albumin (Fraction V, poor in unesterified fatty acids). In the cell cultures treated with heated fats, intracellular lipid accumulation, increased cytoplasmic vacuolization, mitotic aberrations, pyknotic cells, and decreased mitosis were observed and were more pronounced in the case of the heated olive oil. These cytotoxic effects increased with higher concentrations of heated fats in the medium. The fresh fats also produced intracellular lipid accumulation, reductions in mitosis, and changes in the nucleus and cytoplasm, at the higher levels. These effects were greater in fresh olive oil-treated cultures. These observations indicate that oxidized fat components interfere physically or biochemically with normal cell functions resulting in pathological changes.

Chemical and biological properties related to toxicity of heated fats

Heating of fats brings about measurable changes in their chemical and physical characteristics. Heat is applied in processing for food manufacture, such as during hydrogenation of oils with a catalyst, and in frying for meal preparation. Partially hydrogenated products generally contain substantial quantities of geometric and positional isomers of the original unsaturated fatty acids. During deep-fat frying, when the fat is used repeatedly, oxidative and thermal effects result in the formation of many volatile and nonvolatile products, some of which are potentially toxic, depending on the level of intake. Because of concern about the types of changes that take place in fats during oxidative and thermal deterioration and the effects the derivatives could have on the consumer, many chemical and biological studies have been carried out. Experimental findings indicate that any potential danger to the consumer is relative to the severity of the overall treatment of the fat. In some studies we evaluated biological effects on rats of trans fatty acid in the diet and of concentrates of fatty acid derivatives produced in thermally oxidized fats. trans-Octadecenoic acid changed the concentrations of the phospholipid classes in the liver lipids, and interfered with conversion of the essential n - 6 series of fatty acids to higher members. Compared to oleic acid, elaidic acid was preferentially incorporated into the phospholipids instead of the triacylglycerols and was also concentrated in the lipoprotein fractions. Administration of non-urea-adductable concentrates from thermally oxidized fats produced cellular damage in hearts, livers, and kidneys of the animals. Since even practical processing and frying conditions can produce some nutritionally undesirable products, a concerted effort should be made to minimize substantial accumulation of these in our dietary fats.

Effects of vitamin E and ascorbyl palmitate on cultured myocardial cells exposed to oxidized fats

Primary cultures of rat heart cells were used as a model system to study the influence of two antioxidants, vitamin E and ascorbyl palmitate, on biological effects of thermally oxidized fat. The free fatty acid fraction of the distillable non-urea-adductable fraction of heated corn oil (HCO) was used as the test lipid; the free fatty acid fraction of fresh corn oil was the control. HCO (100 microgram/ml medium) depressed the mitotic index, induced excessive lipid accumulation, and increased the number of pyknotic nuclei in the cells. Addition of extra vitamin E (10 microgram/ml medium) reduced the toxicity of HCO by counteracting these changes. In comparison, ascorbyl palmitate (10 microgram/ml medium) in the presence of HCO was beneficial in that it produced only a slight increase in the mitotic index. HCO treatment also resulted in reduced levels of linoleic and arachidonic acids in the phospholipid fractions of the cells, and addition of vitamin E or ascorbyl palmitate increased the level of arachidonic acid. The triacylglycerol fraction of HCO-treated cells showed markedly reduced linoleic acid and increased arachidonic acid. These changes were unaffected by the antioxidant treatments. Vitamin E counteracted the adverse effects of HCO treatment on the rat heart cells. Ascorbyl palmitate only was as efficient as vitamin E in elevating the concentration of arachidonic acid at the membrane level in the presence of HCO.

Lung abscess and empyema of the thorax

Empyema is best managed by the physician familiar with the indications and principals of the various procedures used in the treatment of empyema of the thorax. The objective of each modality used to treat empyema is to drain the pleura cavity and to allow full expansion of the lung. If the infected material can be removed and the visceral and parietal pleural approximated, the body will heal the pleural infection. The procedure chosen to treat empyema greatly depends upon the phase of maturation of the empyema when treatment is begun.