Elucidation of the primary and three-dimensional structure of the uterotonic polypeptide kalata B1

The amino acid sequence and structure of a uterotonic polypeptide extracted from the African plant Oldenlandia affinis DC have been determined. The peptide, kalata B1, consists of 29 amino acid residues and is rich in cysteine (6), threonine (5), and glycine (5). Enzyme cleavage studies show that the polypeptide backbone is cyclic. The three-dimensional solution structure has been determined using two-dimensional nuclear magnetic resonance (NMR) spectroscopy and distance-restrained simulated annealing. Kalata B1 is composed mainly of beta-strands connected by tight turns, forming regions of beta-sheet, except in the case of one section which forms a longer, less structured loop. The tertiary fold, together with the disulfides that form a sulfur core, produces a striking and unusual surface in which the majority of the hydrophobic residues form a solvent-exposed patch. The hydrophobic side of kalata B1 is flanked by two diametrically opposed and opposite-charged residues. The structure calculations have been used to predict the previously unknown disulfide bond connectivities using two approaches. In the first, a family of structures was calculated on the basis of NOE constraints without the assumption of a specific disulfide connectivity. The resultant structures were examined to determine whether the calculated position of the sulfur atoms suggested that one set of disulfide connectivities was more likely than the other, theoretically possible, sets. In the second approach, a separate family of structures (50 per set) was calculated for each of the 15 possible disulfide-bonded molecules. The resultant families of structures were compared to see whether one was favored over the others. Both approaches led to the same global fold, and the most likely disulfide connectivity is predicted to be 5-22, 13-27, and 17-29. In the calculated structure the cyclic peptide backbone is folded back onto itself and braced with disulfide pairs across diagonally opposed beta-strands. This structure involves one of the disulfide bonds (5-22) threading through the eight amino acid loop formed by the other two disulfide bonds and the peptide fragments connecting them.

Universal or selective screening of the neonatal hip using ultrasound? A prospective, randomised trial of 15,529 newborn infants

The aim of this study was to evaluate whether universal (all neonates) or selective (neonates belonging to the risk groups) ultrasound screening of the hips should be recommended at birth. We carried out a prospective, randomised trial between 1988 and 1992, including all newborn infants at our hospital. A total of 15 529 infants was randomised to either clinical screening and ultrasound examination of all hips or clinical screening of all hips and ultrasound examination only of those at risk. The effect of the screening was assessed by the rate of late detection of congenital or developmental hip dysplasia in the two groups. During follow-up of between six and 11 years, only one late-detected hip dysplasia was seen in the universal group, compared with five in the subjective group, representing a rate of 0.13 and 0.65 per 1,000, respectively. The difference in late detection between the two groups was not statistically significant (p = 0.22). When clinical screening is of high quality, as in our study, the effect of an additional ultrasound examination, measured as late-presenting hip dysplasia, is marginal. Under such circumstances, we consider that universal ultrasound screening is not necessary, but recommend selective ultrasound screening for neonates with abnormal or suspicious clinical findings and those with risk factors for hip dysplasia.

Inflammatory aortic aneurysm is associated with increased incidence of autoimmune disease

OBJECTIVE

It has been suggested that certain genetic risk factors indicative of an autoimmune mechanism can be identified in patients with inflammatory aortic aneurysm (IAA). We therefore investigated whether there was a higher incidence of autoimmune diseases in patients with IAA. Further, we explored risk factors, need for in-hospital resources, and early results of treatment, in a case-control study in a university hospital setting. Material and methods From 1983 to 1994, 520 patients were operated because of abdominal aortic aneurysm (AAA). Thirty-one patients had IAA. Control subjects were matched for aneurysm rupture, emergency or elective hospital admission, and date of operation. Two noninflammatory AAA were included for every IAA.

RESULTS

Of the 31 patients with IAA, 6 patients (19%) had autoimmune disease, compared with none of the control subjects (P =.0017). Two patients had rheumatoid arthritis, 2 patients had systemic lupus erythematosus, 1 had giant cell arteritis, and 1 patient had an undifferentiated seronegative polyarthritis diagnosed as rheumatoid arthritis. Nineteen patients (61%) with IAA had involvement of the duodenum, and 8 patients (26%) had hydronephrosis with ureteral involvement. Operating time was longer in the IAA group, which also had a higher need for blood transfusion. Hospital stay, intensive care unit stay, and 30-day mortality were similar in the two groups.

CONCLUSION

Except for longer operating time and more need for blood transfusions in the IAA group, use of hospital resources was similar after operations to treat IAA or noninflammatory AAA. The study findings indicate an association between IAA and autoimmune disease. This is in accordance with other reports that showed a genetic risk determinant mapped to the human leukocyte antigen (HLA) molecule in these patients. Further research is necessary to explore whether IAA might be a separate entity with a role of antigen binding in the origin of the disease.

Differences in neurotransmitter synthesis and intermediary metabolism between glutamatergic and GABAergic neurons during 4 hours of middle cerebral artery occlusion in the rat: the role of astrocytes in neuronal survival

Astrocytes are intimately involved in both glutamate and gamma-aminobutyric acid (GABA) synthesis, and ischemia-induced disruption of normal neuroastrocytic interactions may have important implications for neuronal survival. The effects of middle cerebral artery occlusion (MCAO) on neuronal and astrocytic intermediary metabolism were studied in rats 30, 60, 120, and 240 minutes after MCAO using in vivo injection of [1-13C]glucose and [1,2- 13C]acetate combined with ex vivo 13C magnetic resonance spectroscopy and high-performance liquid chromatography analysis of the ischemic core (lateral caudoputamen and lower parietal cortex) and penumbra (upper frontoparietal cortex). In the ischemic core, both neuronal and astrocytic metabolism were impaired from 30 minutes MCAO. There was a continuous loss of glutamate from glutamatergic neurons that was not replaced as neuronal glucose metabolism and use of astrocytic precursors gradually declined. In GABAergic neurons astrocytic precursors were not used in GABA synthesis at any time after MCAO, and neuronal glucose metabolism and GABA-shunt activity declined with time. No flux through the tricarboxylic acid cycle was found in GABAergic neurons at 240 minutes MCAO, indicating neuronal death. In the penumbra, the neurotransmitter pool of glutamate coming from astrocytic glutamine was preserved while neuronal metabolism progressively declined, implying that glutamine contributed significantly to glutamate excitotoxicity. In GABAergic neurons, astrocytic precursors were used to a limited extent during the initial 120 minutes, and tricarboxylic acid cycle activity was continued for 240 minutes. The present study showed the paradoxical role that astrocytes play in neuronal survival in ischemia, and changes in the use of astrocytic precursors appeared to contribute significantly to neuronal death, albeit through different mechanisms in glutamatergic and GABAergic neurons.

Efficient secretion of human parathyroid hormone by Saccharomyces cerevisiae

A cDNA encoding mature human parathyroid hormone (hPTH) was expressed in Saccharomyces cerevisiae, after fusion to the prepro region of yeast mating factor alpha (MF alpha). Radioimmunoassay showed high levels of hPTH immunoreactive material in the growth medium (up to 10 micrograms/ml). More than 95% of the immunoreactive material was found extracellularly as multiple forms of hormone peptides. Three internal cleavage sites were identified in the hPTH molecule. The major cleavage site, after a pair of basic amino acids (aa) (Arg25Lys26 decreases Lys27), resembles that recognized by the KEX2 gene product on which the MF alpha expression-secretion system depends. The use of a protease-deficient yeast strain and the addition of high concentrations of aa to the growth medium, however, not only changed the peptide pattern, but also resulted in a significant increase in the yield of intact hPTH (1-84) (more than 20% of the total amount of immunoreactive material). The secreted hPTH (1-84) migrates like a hPTH standard in two different gel-electrophoretic systems, co-elutes with standard hPTH on reverse-phase high-performance liquid chromatography, reacts with two hPTH antibodies raised against different parts of the peptide, has a correct N-terminal aa sequence, and has full biological activity in a hormone-sensitive osteoblast adenylate cyclase assay.

The use of MRI in the investigation of leg oedema

Magnetic resonance imaging (MRI) was used in the diagnosis of various conditions giving rise to leg oedema, with special attention to the oedema after femoro-distal vascular reconstruction for obliterative atherosclerosis (n = 14). Patients with deep venous thrombosis (n = 6), chronic lymphoedema (n = 6) and closed muscular compartment syndrome (n = 2) were also investigated. Leg volume increase was measured according to the formula of a truncated cone. Interstitial fluid hydrostatic pressure (Pif) was recorded with the wick-in-needle technique. Spin echo series with 10 mm transverse slices were obtained with MRI. Following vascular reconstructions, leg volume increased 26% on the operated side. In the operated leg, no gradient in Pif was found between the posterior muscular compartment and the subcutaneous tissue. However, there was a significantly higher Pif in the subcutaneous tissue compared to the anterior muscular compartment (p less than 0.05). In the operated group, MRI revealed oedema around the entire circumference of the leg, mainly restricted to the subcutaneous tissue. In contrast, oedema of the leg muscles, particularly in the posterior compartments, was typical for patients having deep venous thrombosis. The group with chronic lymphoedema showed circumferential subcutaneous oedema alone or in combination with a fibrotic honeycomb pattern. Oedema of the affected muscular compartment was easily observed in patients who had a closed compartment syndrome. In conclusion, the use of MRI is promising in the investigation of conditions giving rise to leg oedema. It is likely that the formation of post-reconstructive oedema is taking place in the subcutaneous tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasound screening for hip dysplasia in newborns

We evaluated risk factors for neonatal hip instability (NHI) at birth using ultrasonography and assessed the reliability of our ultrasound method by means of an interobserver study. The hips of 4,459 newborns were examined by ultrasound from 1988 to 1990. The ultrasound evaluation was based mainly on measurement of femoral head coverage (FHC) by the bony acetabular roof. The mean FHC was 56% in boys and 54% in girls (a significant difference). Fifty-five newborns with unstable hips had a mean FHC of 37%, which was significantly lower than that of the normal hips. Known risk factors for NHI were confirmed (breech position, family history of hip dysplasia, increased birth weight), but no new risk factors were detected. The interobserver study included 200 hips. The 95% confidence limit for interobserver variation in FHC (+/- 2 SD) was +/- 8%. Because of this moderate interobserver variation, and because the incidence of late-detected hip dysplasia was low (0.2 per 1,000), we conclude that our method for ultrasound examination is sufficiently reliable for screening of hips in newborns.

Lymph drainage and the development of post-reconstructive leg oedema is not influenced by the type of inguinal incision. A prospective randomised study in patients undergoing femoropopliteal bypass surgery

OBJECTIVES

To see whether the type of groin incision influenced the degree of postoperative leg oedema and the occurrence of lymphatic damage.

DESIGN

Prospective randomised clinical study.

SETTING

University Department of Surgery.

MATERIALS

Twenty-four patients undergoing femoropopliteal bypass reconstruction with either a lateral groin incision (Group A, n = 12) or a direct incision over the femoral vessels (Group B, (n = 12).

CHIEF OUTCOME MEASURES

The leg volume increase was measured according to the formula of a truncated cone. Deep venous thrombosis was excluded by air plethysmography and colour-coded Duplex scanning. Lymphatic lesions were detected by lymphoscintigraphy using 99mTc labelled human serum albumin.

MAIN RESULTS

One week following vascular reconstruction the median leg volume increase was 24.5% in Group A vs. 23.3% in Group B (NS). Lymphoscintigraphy revealed obstruction of the lymphatics in five patients of Group A vs. three patients of Group B (NS). Neither the occurrence of lymph cysts nor extravasation of lymph differed between the two groups. In seven patients no lymphatic lesion was observed. Patients with interruption of the lymphatics (n = 8) had a higher leg volume increase compared to the remaining patients with no or minor lymphatic lesions, 31.2% vs. 19.6%, respectively (p < 0.05).

CONCLUSIONS

Leg oedema and the occurrence of lymphatic damage following femoropopliteal bypass surgery is not reduced by applying a lateral approach to the femoral artery in the groin. However, the higher leg volume increase in patients with lymphatic obstruction indicates that lymphatic damage could play a part in the leg oedema formation.

Cerebral haemodynamics during thoracic- and thoracoabdominal aortic aneurysm repair

OBJECTIVE

To investigate cerebral haemodynamics during operations for thoracic and thoracoabdominal aortic aneurysms.

DESIGN

Prospective clinical study.

MATERIAL

10 patients operated on consecutively with resection for thoracic (5) or thoracoabdominal aortic (5) aneurysms.

METHODS

Blood flow velocity of the middle cerebral artery was measured through a temporal approach using a TC Doppler with a 2 MHz probe. Recordings were made during induction of anaesthesia and performed continuously before, during and after cross-clamping of the aorta.

RESULTS

Following 10 min. of aortic cross-clamping blood flow velocity of the middle cerebral artery increased from 44 to 55 cm/s (p < 0.01). A further increase to 69 cm/s (p < 0.01) was observed 5 min after declamping. The pulsatility index averaged 0.74 increasing to 1.21 (p < 0.05) at clamping and 0.87 (p < 0.05) after declamping.

CONCLUSION

There was an increased blood flow velocity of the middle cerebral artery during cross-clamping of the descending thoracic aorta in patients operated on for thoracic and thoracoabdominal aortic aneurysms. This increase in cerebral blood flow and blood volume could explain the acute increase in cerebrospinal fluid pressure observed during cross-clamping of the thoracic aorta.

Quality of Data Reported on Abdominal Aortic Aneurysm Repair—A Comparison between a National Vascular and a National Administrative Registry

OBJECTIVE

To study consistency of data and completeness of reporting in a national vascular registry, NorKar, and a national administrative registry, The Norwegian patient register (NPR).

DESIGN

Comparative registry-based national study supplemented with a comprehensive control of patients registered in one major hospital.

MATERIAL

All patients registered with a procedure-code for treatment of AAA in NorKar or NPR during 2001 or 2002, were included.

METHOD

We compared the reporting of procedure-codes, diagnosis-codes and in-hospital deaths after treatment for abdominal aortic aneurysm (AAA) in the two registries to evaluate completeness. Consistency between procedure-codes and diagnoses were evaluated within both registries. Completeness of reporting to one NorKar Local Registry was investigated in more detail in one of the hospitals.

RESULTS

Compared with the NPR numbers, NorKar contained 69% of the patients treated for AAA in Norway, while completeness for NorKar member hospitals was 84%. The detailed investigation in one of the hospitals showed a completeness of 91% and a false inclusion of 5.3% of all cases treated for AAA. The consistency between procedure-codes and diagnosis-codes was 93% in both registries. We found evidence of substantial underreporting of in-hospital deaths to NorKar in several hospitals. Overall reporting of early deaths to NorKar relative to completeness of reported cases was estimated to 72%.

CONCLUSION

There is an underreporting of patients with AAA to NorKar according to the NPR numbers and a need for better control of procedure-diagnosis consistency in both registries. There seems to be a substantial underreporting of early deaths to NorKar. Introduction of unique patient-identifiable data could improve the quality of both registries by making matching of data possible.

Changes in hemodynamics and acid-base balance during cross-clamping of the descending thoracic aorta. A study in patients operated on for thoracic and thoracoabdominal aortic aneurysm

AIM OF THE STUDY

In the clinical situation there is discrepancy between various investigations regarding the cardiac response of thoracic aortic cross-clamping. The aim was therefore to investigate the hemodynamic response and blood gases during proximal aortic cross-clamping (XC) in patients operated for descending thoracic and thoracoabdominal aortic aneurysm without circulatory support.

PATIENTS AND METHODS

Altogether 51 patients operated on for thoracoabdominal (n=31) or descending thoracic aortic aneurysm (n=20) were included in the investigation. All patients were operated with aortic XC, but no circulatory support was applied. Hemodynamic variables and blood gases were recorded before and during XC.

RESULTS

A significant increase in cardiac output during XC from 4.7 to 6.0 liters/min was observed (p<0.01). There was a similar percentual increase in heart rate and also the proximal systolic blood pressure increased. A metabolic acidosis occurred during XC.

CONCLUSION

Cardiac output was significantly increased during XC in patients operated on for thoracoabdominal or descending thoracic aneurysm using direct aortic XC without circulatory support. Simultaneously, the heart rate was increased and there was a hyperdynamic circulatory state proximal to the aortic clamp. Redistribution of the blood volume in addition to catecholamine release may be responsible for the observed changes. These observations may influence the selection of operative strategy for some of these patients.

Expression of human parathyroid hormone in Escherichia coli

Human parathyroid hormone (hPTH) is a peptide hormone consisting of 84 amino acids. Using the expression plasmid pKK223-3 with the strong tacpromoter, we have produced a variant of hPTH in E. coli. From the expression plasmid construct the expected product was hPTH with an N-terminal extension of Met-Gly. The peptide was extracted from E. coli cells and purified by high performance liquid chromatography. In two different gel electrophoresis systems including identification by immunoblotting the product behaved exactly as an hPTH standard. N-terminal amino acid sequence analysis of the purified product showed traces of Gly-hPTH. At least 90% of the expressed product was N-terminally blocked, suggesting the presence of N-formyl-methionine. This variant of hPTH did not stimulate adenylate cyclase activity in rat osteosarcoma cell membranes.

Studies on recombinant Acetobacter xylinum alpha-phosphoglucomutase

The phosphoglucomutase (PGM) from Acetobacter xylinum, which had been cloned and expressed in Escherichia coli, has been studied. After expression, the enzyme was purified from the E. coli in a three-step process consisting of (NH4)2SO4 precipitation, gel filtration and anion-exchange chromatography. The purified enzyme gave one band on gel electrophoresis and was judged essentially free of impurities, although it was unstable when diluted without the addition of 15 microM BSA. The isoelectric point for A. xylinum PGM was 4.8 and the molar absorbance was 3.9 x 10(4) M-1.cm-1. The enzyme was reasonably heat-stable below 50 degrees C and was stable throughout the pH 5.5-7.4 range, but was 70% inactivated at pH 10.0 and completely inactivated after standing for 10 min at pH 3.0 or at pH 12.4. When isolated, the recombinant enzyme was fully active without the addition of extra Mg2+. The Km for glucose 1-phosphate was much higher than that of other PGM species reported, which accords with the production of extracellular cellulose in A. xylinum. Glucose 1,6-diphosphate is not considered to be a substrate or coenzyme but an activating cofactor like Mg2+. The following kinetic constants were determined: Vmax 81.1 units/mg; kcat and the turnover rate 135 s-1; Km (glucose 1,6-diphosphate) 0.2 microM; Km (glucose 1-phosphate) 2.6 mM; kcat/Km (glucose 1-phosphate) 5.2 x 10(4) M-1.s-1. The recombinant enzyme is considered to follow a characteristic substituted enzyme or Ping Pong reaction mechanism.

Winner of the ESVS prize 1989. Microcirculation of the spinal cord during proximal aortic cross-clamping

The relationship between the cerebrospinal fluid pressure (CSFP) and the microcirculation of the spinal cord was studied during cross-clamping (XC) of the thoracic aorta in pigs. CSFP was recorded via an intrathecal catheter. The microcirculation was measured by the laser Doppler technique using a needle probe inserted percutaneously into the spinal cord. A left thoracotomy was performed, and the thoracic aorta was cross-clamped for 30 minutes distal to the left subclavian artery. Prior to XC a pulsatile flux recording from the spinal cord (SCF) was observed. Following cross-clamping of the aorta SCF was dramatically reduced (P less than 0.001), then stabilised at 40% of base-line values. During XC, variations in CSFP were observed but these changes were not statistically significant. CSFP gradually increased to pre cross-clamp levels following release of XC (P less than 0.05). SCF increased 51% following removal of 1 ml of cerebrospinal fluid (P less than 0.05). By injection of 0.9% saline at body temperature SCF was totally inhibited at CSFP above 15 mmHg. Occlusion of the azygos vein increased CSFP 1.3 mmHg (P less than 0.05) whereby SCF decreased 58% (P less than 0.01). Following release of XC of a hyperaemic period of the SCF was demonstrated in ten out of 13 animals. In conclusion, SCF was significantly influenced by changes in CSFP during XC of the thoracic aorta. The findings support the theory that removal of spinal fluid during XC of the thoracic aorta may increase the perfusion pressure to the spinal cord, thereby improving its blood supply.

1,25-dihydroxyvitamin D-3 and 24,25-dihydroxyvitamin D-3 affect parathormone (PTH) -sensitive adenylate cyclase activity and alkaline phosphatase secretion of osteoblastic cells through different mechanisms of action

In UMR 106 rat osteosarcoma cells, parathormone (1-34hPTH) and calcitonin (sCT) stimulated adenylate cyclase (AC) activity 5.5-and 2.8-fold, respectively. AC in osteoblasts (OB) from collagenase-treated calvaria of 3-day-old rats responded similarly to 1-34hPTH. In contrast, fibroblasts (mouse fibroblastomas) displayed a marginal 1-34hPTH sensitive AC. Osteoclasts (OC) of collagenase-treated rat calvariae, rat monocytes and mouse macrophages did not demonstrate 1-34hPTH inducable AC activity. Physiological concentrations of 24,25-dihydroxyvitamin D-3 attenuated PTH-sensitive AC in OB and UMR 106 cells within 20 min, while 1,25-dihydroxyvitamin D-3 showed no such immediate effect. In contrast, the AC response to Gpp(NH)p was unaffected by 24,25-(OH)2D3, indicating that 24,25-(OH)2D3 interrupts the coupling of the PTH receptor to the GTP binding protein Gs. OB and UMR 106 cells were also subjected to long-term (48 h) incubation with vitamin D-3 metabolites, 1-34hPTH or 20% serum from patients with secondary hyperparathyroidism (sHBT-serum), respectively. PTH-sensitive AC was markedly attenuated by pre-exposure to both 1-34hPTH and 1,25-(OH)2D3, while minimally affected by corresponding 24,25-(OH)2D3 and 20% sHPT-serum treatment. The secretion of alkaline phosphatase (Alphos) from the two cell types was strongly increased by 1-34hPTH, the effect being abolished by the presence of 24,25-(OH)2D3. Iliac crest biopsies of normal individuals exhibited a clear negative correlation between PTH-sensitive AC and corresponding serum 24,25-(OH)2D3 levels. Basal AC activity was, however, negatively correlated to serum 1,25-(OH)2D3 concentrations. In summary, the results show that 24,25-(OH)2D3 reduces PTH-stimulated AC activity in and Alphos secretion from osteoblastic bone cells by rapidly and directly interfering with the plasma membrane. These data reinforce the probable in vivo significance of 24,25-(OH)2D3. Moreover, the negative correlation between basal AC activity and serum 1,25-(OH)2D3 levels indicates a possible role for 1,25-(OH)2D3 in regulating bone cell synthesis of AC components in vivo.

Shunting of the Coeliac and Superior Mesenteric Arteries during Thoracoabdominal Aneurysm Repair

OBJECTIVES

To describe our experience with shunting of the coeliac and superior mesenteric arteries during thoracoabdominal aneurysm repair.

DESIGN

Retrospective study.

MATERIAL

Eight patients undergoing resection and graft replacement of Crawford type III (5) and type IV (3) thoracoabdominal aortic aneurysms were included in this series. One patient had rupture, four were symptomatic and three were operated on electively.

METHODS

A vascular graft with a sidearm was applied for the reconstructions. A T-shunt was connected to the sidearm. Following completion of the proximal anastomosis the shunt was inserted into the coeliac and superior mesenteric arteries. The anastomoses to these arteries and the renal arteries were then completed. Finally the distal anastomosis was performed.

RESULTS

There was no early mortality (30 days). One patient had postoperative paraparesis, but recovered quite well. Reoperation became necessary due to sigmoid necrosis in one patient and due to haemorrhage in another. During the follow-up period four patients died but the other patients are alive between 3 and 8 years after surgery.

CONCLUSION

The application of shunting of the superior mesenteric and coeliac arteries during thoracoabdominal aortic surgery is feasible and the results have been acceptable. Further investigation of the optimal blood flow needed to avoid intestinal ischaemia in a larger series of patients is desirable.

Cerebral haemodynamics during proximal aortic cross-clamping

This study was carried out to examine cerebral blood flow, including the microcirculation and intracranial pressure during cross-clamping (XC) of the thoracic aorta in pigs. Blood flow in the internal carotid artery was measured by electromagnetic flowmetry. Cerebral microcirculation was studied by the laser Doppler technique, and intracranial pressure measured by applying a fibre optic pressure monitoring catheter in the same craniotomy. Maximal and mean blood flow velocity of the middle cerebral artery was recorded using a transcranial Doppler and cardiac output measured by thermodilution. The thoracic aorta was cross-clamped distal to the left subclavian artery for 30 min. During aortic XC the internal carotid artery blood flow increased 191% (p less than 0.05). Simultaneously mean and maximal blood flow velocity of the middle cerebral artery both increased 125% (p less than 0.01). Intracranial pressure increased 163% (p less than 0.05), and there was an increase in cerebral flux of 23% (p less than 0.05). Within the first minutes following the release of XC, all values decreased to preocclusive values. In conclusion, we observed a significant increase in cerebral blood flow during XC of the thoracic aorta. This is in accordance with the finding of a simultaneous increase in cardiac output. These haemodynamic changes support the theory that an increased blood flow via the proximal feeding system to the anterior spinal artery might be important in avoiding neurological sequelae following proximal aortic XC.

Spinal cord metabolism during thoracic aortic cross-clamping in pigs with special reference to the effect of allopurinol

OBJECTIVE

investigate the metabolic response of the spinal cord and the effect of allopurinol following cross clamping of the descending thoracic aorta in a porcine model.

DESIGN

experimental animal study.

MATERIALS

twelve domestic swine. Six pigs were pre-treated with allopurinol, while six pigs served as controls.

METHODS

measurement of extracellular concentrations of glucose, pyruvate, lactate, glycerol and glutamate using microdialysis in the lumbar spinal cord. Measurement of lumbar spinal blood flow using laser Doppler technique.

RESULTS

for all animals there was a significant decrease in concentrations of glucose and pyruvate together with a significant increase in the lactate-pyruvate ratio during aortic cross clamping. There was also a significant increase in glycerol concentrations 60 min after cross clamping, and a significant decrease in glutamate concentrations after 50 min. No differences in concentrations of glucose, pyruvate, lactate and glutamate or the glutamate-pyruvate ratio were observed between animals used as controls and those treated with allopurinol. The laser Doppler flux decreased to 40% of pre cross-clamp level, returning to normal values at declamping.

CONCLUSION

the changes in energy-related metabolites reflect a considerable ischaemia in the spinal cord tissue but there was no convincing effect of allopurinol on the lumbar spinal cord metabolism during thoracic aortic cross clamping in this model.

Microdialysis of the spinal cord during thoracic aortic cross-clamping in a porcine model

OBJECTIVE

Utilising microdialysis to measure the changes of glucose, lactate, pyruvate and glutamate levels in the spinal cord after cross-clamping of the thoracic aorta in an established porcine model to monitor the degree of ischaemia.

DESIGN

Experimental study with a porcine model.

SETTING

University Hospital, Trondheim.

SUBJECTS

Six pigs.

MAIN OUTCOME MEASURE

Lactate, pyruvate and glutamate concentrations in the microdialysis perfusate from the spinal cord.

RESULTS

A significant increase of the lactate-pyruvate ratio during the last 30 min of the 1 h clamping period, with a maximum increase of 169% from the basal value the last 10 min before declamping. No evident change in this ratio between the clamping and the reperfusion period. No significant change in glutamate levels during clamping or reperfusion period.

CONCLUSION

Microdialysis reflects the ischaemic state of the spinal cord during cross-clamping of the thoracic aorta in pigs, and is well suited to study each phenomena.

Ultrasound imaging during endovascular abdominal aortic aneurysm repair using the Stentor bifurcated endograft

PURPOSE

To evaluate different ultrasound modalities during implantation and follow-up of endovascular grafts for abdominal aortic aneurysm (AAA) exclusion.

METHODS

Between February 1995 and May 1996, 18 patients (14 men; aged 49 to 80 years, mean 67) were treated with endovascular intervention for infrarenal AAA. Seventeen patients received Mialhe Stentor bifurcated grafts, while one patient was treated with a straight graft for pseudoaneurysm. During and after the implantation, 3.25- and 5-MHz annular array ultrasound probes were used for transabdominal visualization of the endograft. Intravascular ultrasound was applied in combination with angiography for postoperative control.

RESULTS

Intraprocedurally, transabdominal two-dimensional (2D) ultrasound successfully monitored guidewire passage from the groin into the main part of the bifurcated endograft for implantation of the second limb. All implantation procedures were technically successful, but four endoleaks were identified intraprocedurally by 2D ultrasound and angiography. One healed spontaneously, two were treated with endovascular techniques at 1 and 4 months, and the last leak was scheduled for repair when the patient died of probable myocardial infarction at 2 months. During follow-up, 2D ultrasound successfully visualized all the endografts; no endoleaks were found in up to 18 months of surveillance.

CONCLUSIONS

Transabdominal ultrasound imaging could be valuable in bifurcated endograft deployment both for guiding guidewire insertion and for controlling wire position before the second graft limb is connected to the main graft. Provided that satisfactory visualization of the entire endograft can be obtained, ultrasound examination may possibly replace arteriography and computed tomographic scanning as a follow-up investigation.

The importance of transesophageal echocardiography during surgery of the thoracic aorta

OBJECTIVES

To assess left ventricular dimensions and cardiac output during thoracic and thoracoabdominal aortic aneurysm repair.

MATERIAL AND METHODS

Nine patients undergoing thoracic and thoracoabdominal aneurysm repair using direct cross-clamping without shunt or by-pass were studied prospectively. Prior to, during cross-clamping (XC) and after declamping left ventricular cross-sectional areas were monitored with transesophageal echocardiography. A pulmonary artery catheter was used for measurements of cardiac output with the thermodilution technique.

RESULTS

Cardiac output increased 43% from baseline during XC (p < 0.01) and was still 55% above baseline at declamping (p < 0.05). Left ventricular end-systolic inner area was reduced 32% during XC (p < 0.01). Pulmonary artery pressures and central venous pressure increased during declamping (p < 0.05). Heart rate increased 38% from 66 beats/ min to 92 beats/min (p < 0.01) and was still 30% elevated at declamping (p < 0.01).

CONCLUSION

During thoracic aortic XC, cardiac output is increased and left ventricular end-systolic dimension is reduced. TEE is a valuable supplement to pressure measurements for the evaluation of cardiac function during surgery of the thoracic aorta.

Alterations in intracranial volume following cross-clamping of the descending thoracic aorta in pigs--an experimental study using MRI

OBJECTIVES

To determine whether alterations in intracranial volume occurred following cross-clamping of the descending thoracic aorta in pigs.

DESIGN AND SETTING

Laboratory animal study.

MATERIALS

Eight pigs undergoing cross-clamping of the descending thoracic aorta for 30 min.

CHIEF OUTCOME MEASURES

A Philips Gyroscan T5-II Release 3 (0.5 T) was used to obtain intracranial images before cross-clamping, during cross-clamping and after declamping. The ventricular volume was measured on Spin Echo T1-weighted images. The signal intensity of the cerebral tissue was measured on Spin Echo T2-weighted images. Increased signal intensity of the cerebral tissue relative to an external reference was used as an indicator of cerebral oedema.

MAIN RESULTS

The ventricular volume decreased to 89% (p < 0.01) of the baseline value after 5 min of cross-clamping. At 5 min after declamping the ventricular volume decreased further to 71% (p < 0.01). At 25 min after declamping the ventricular volume had returned to the baseline value. The signal intensity of the cerebral tissue did not differ from baseline values following aortic cross-clamping.

CONCLUSIONS

In this study, ventricular volume decreased following cross-clamping of the descending thoracic aorta. Since no cerebral oedema was observed, the decrease of ventricular volume was most likely due to increased intracranial blood volume.

Gray matter metabolism in acute and chronic hydrocephalus

Although hydrocephalus is usually considered a disorder of periventricular white matter, disturbance of gray matter is probably also involved. However, so far gray matter metabolism has not been studied in experimental hydrocephalus using high resolution in vivo magnetic resonance spectroscopy (MRS). Therefore 15 rats were made hydrocephalic by injection of 0.1 ml kaolin into the cisterna magna, whereas 10 sham-operated rats served as controls. (1)H MRS and magnetic resonance imaging were performed longitudinally in acute hydrocephalus 2 and 4 weeks after kaolin treatment and in chronic hydrocephalus after 6 weeks. Volumes of interest included the gray matter regions cortex, thalamus and hippocampus. In hydrocephalic animals, (1)H MRS revealed decreased glutamate levels in all examined areas at all time points. Moreover, in acute hydrocephalus disturbances were noted in the hippocampus with decreased concentrations of N-acetyl aspartate, creatine, inositol and taurine, and in the cortex with decreased taurine levels. A clear lactate peak was detected in CSF spectra from hydrocephalic rats. In addition, T2-weighted images showed increase of free water in the hippocampus. It can be concluded that glutamate metabolism is deranged in gray matter in acute and chronic hydrocephalus in rats. If confirmed in humans, early detection of glutamatergic disturbances and lactate accumulation using in vivo(1)H MRS might serve as an indication for surgical treatment of hydrocephalus before irreversible neuronal damage develops.