Risk factors for systolic dysfunction and ventricular dilatation in hypertrophic cardiomyopathy

The history of an 18-year-old male with hypertrophic cardiomyopathy (HCM) and ventricular dilatation is presented and the literature on systolic dysfunction and ventricular dilatation in patients with HCM is statistically analyzed in search of risk factors. The patient was followed for 7 years when he developed recurrent ventricular fibrillation, left ventricular dilatation and low cardiac output. An automatic cardioverter-defibrillator was implanted but the patient died of electro-mechanical dissociation. In order to define risk factors for systolic dysfunction and ventricular dilatation in HCM, the literature data of 17 patients with this complication were compared to a group of 139 consecutive patients with HCM from our hospital. The risk factors identified were a more markedly increased septal (20.1 vs. 18.0 mm, P < 0.05) and posterior wall thickness (13.6 vs. 11.0 mm, P < 0.001) in the patients subsequently developing systolic dysfunction and ventricular dilatation, whereas age, sex and the ratio between septal and posterior wall thickness were not significantly different between the two groups. A severely increased ventricular mass appears to be a risk factor for the development of systolic dysfunction with ventricular dilatation in HCM. Prognosis is usually poor and the reported case showed fatal ventricular arrhythmia despite the implantation of an automatic cardioverter-defibrillator.

Isolation of naturally processed peptides recognized by cytolytic T lymphocytes (CTL) on human melanoma cells in association with HLA-A2.1

Cytolytic T lymphocyte (CTL) clones have previously been derived from peripheral blood of melanoma patient SK29(AV). They lyse autologous melanoma cells but not autologous Epstein-Barr virus (EBV)-transformed B lymphocytes. Immunoselection experiments indicate that these CTL clones recognize 4 different antigens (Aa, Ab, B, C) in association with a single HLA restriction element, HLA-A2.1. While the expression of antigens B and C appears to be confined to SK29-melanoma cells, antigens Aa and Ab are shared by a high proportion of allogeneic HLA-A2-positive melanoma lines. HLA-A2.1 and total HLA class I molecules have now been purified from SK29-melanoma cells using affinity chromatography and associated peptides have been eluted. Peptide pools eluted from HLA-A2.1 and total class I were separated by reversed phase high performance liquid chromatography (HPLC). Individual HPLC fractions were tested for their ability to sensitize target cells for recognition by SK29-CTL clones. The presence of antigens Aa, Ab, B and C was detected in distinct HPLC fractions that were identical for both peptide pools. As target for detection of peptide antigens in HPLC fractions, the use of the HLA-A2.1-positive antigen processing mutant cell line CEM x 721.174.T2 (T2), pre-incubated with anti-HLA-A2 monoclonal antibody (MAb) MA2.1, was shown to be essential. Single-peak target-sensitizing activity was found for antigens Ab and B, whereas multi-peak sensitizing activity was reproducibly detected for antigens Aa and C. We reason that at least some of these melanoma peptide antigens might occur in biochemically distinct isoforms.

[Obesity in the elderly and very elderly--prognostic significance and practical conclusions]

Epidemiological work on the age-dependency of the relation between overweight and mortality confirms an opinion which is traditional among physicians and has it roots in a mixture of biological understanding and common sense. The data base can be summarized in three points: 1) Up to the age of 60-65 years, overweight is combined with decreased life expectancy. The excess mortality is found mainly in the cardiovascular area and can be explained by the well-known risk factors of atherosclerosis. In the Framingham-study, overweight per se is a risk factor for this group of diagnoses. 2) In the age group 65-74 years, the relation between overweight and excess mortality vanishes gradually; the right arm of the U- or J-curve levels off. The optimal BMI moves to the right, and the right arm of the curve is shortened. 3) In high age, from 75-80 years on, overweight coincides with improved prognosis. The geriatric literature is in agreement in the sense that overweight is no problem in high age.

High-intensity chemotherapy with peripheral blood progenitor cell support

In a series of clinical studies at Memorial Sloan-Kettering Cancer Center, we have used hematopoietic growth factors and peripheral blood-derived hematopoietic progenitor cells to facilitate delivery of multiple courses of high-dose chemotherapy at abbreviated treatment intervals. In these studies, we have demonstrated the feasibility of cross-over regimens involving induction chemotherapy with high-dose cyclophosphamide, supported by granulocyte colony-stimulating factor and followed by multiple peripheral blood leukapheresis to harvest progenitor cells. These cells are then used as rescue for the consolidation component of treatment, which, in the earlier-generation studies, consisted of a single course of high-dose carboplatin/etoposide/cyclophosphamide chemotherapy. In subsequent studies, patients received either four courses of high-dose carboplatin or carboplatin/cyclophosphamide or tandem courses of thiotepa. In all cases, the planned interval between treatments was 14 days, and the achieved median was approximately 16 days. These studies show that the administration of high-intensity regimens that deliver multiple courses of very high-dose chemotherapy at relatively brief intervals is feasible. Our current research focuses on exploiting these findings to devise disease-specific regimens for breast and ovarian cancer.

Two tyrosinase nonapeptides recognized on HLA-A2 melanomas by autologous cytolytic T lymphocytes

A number of cytolytic T lymphocyte (CTL) clones derived from several melanoma patients have been found to recognize a majority of melanomas from HLA-A2 patients. We have reported previously that two such CTL clones recognize a product of the tyrosinase gene that is presented by HLA-A2. Here we show that one of these CTL clones recognizes a peptide encoded by the first nine amino acids of the putative signal sequence of tyrosinase. The other CTL clone recognizes a different tyrosinase peptide corresponding to amino acids 368-376. Both peptides contain consensus motifs of HLA-A2 binding peptides.

The beagle dog as a predictor of gastrointestinal findings in humans caused by the prostacyclin analogue taprostene

Beagle dogs were exposed orally to the prostacyclin analogue taprostene for four weeks. Dose levels of 200-3000 micrograms/kg body weight/day were used. Specific activity of taprostene on the digestive system compared to other species is reported. It is characterized by hypermotility of the gastrointestinal tract resulting in intestinal invagination in some animals. Gastrointestinal symptoms occurred also after intravenous administration indicating a systemic stimulating effect on smooth muscles. Concerning reversible gastrointestinal side effects in humans after intravenous infusion of prostacyclin the results of this subacute toxicity study indicated that the dog is an adequate and sensitive species for preclinical testing of prostacyclins.

Aprotinin does not decrease early graft patency after coronary artery bypass grafting despite reducing postoperative bleeding and use of donated blood

Forty-five male patients with planned coronary artery bypass operation were randomized in a double blind fashion to receive either 6 million kallikrein inactivator units of aprotinin (high-dose group), 2 million kallikrein inactivator units of aprotinin (low-dose group), or placebo (control group). Postoperative bleeding was significantly decreased in both aprotinin groups in comparison to that in the control group (590 ml [290 to 1800 ml] high-dose group and 650 ml [280 to 1900 ml] low-dose group versus 920 ml (350 to 2700 ml) control group, p < 0.001). There was no difference between the two aprotinin groups. The need for postoperative blood transfusion was significantly lower in the aprotinin groups (1.46 [0 to 4] blood units high-dose group and 1.65 [0 to 5] blood units low-dose group versus 2.43 [0 to 7] blood units control group, p < 0.05). All patients underwent coronary angiography between the seventh and twelfth postoperative day. No difference was found among the three groups in patency of vein grafts-93.8% in the high-dose group, 94.5% in the low-dose groups, and 93.3% in the control group. Therefore, aprotinin significantly reduced postoperative bleeding and transfusion requirement after coronary artery bypass grafting without influencing early graft patency.

Distinctive acceptor-end structure and other determinants of Escherichia coli tRNAPro identity

The previously uncharacterized determinants of the specificity of tRNAPro for aminoacylation (tRNAPro identity) were defined by a computer comparison of all Escherichia coli tRNA sequences and tested by a functional analysis of amber suppressor tRNAs in vivo. We determined the amino acid specificity of tRNA by sequencing a suppressed protein and the aminoacylation efficiency of tRNA by examining the steady-state level of aminoacyl-tRNA. On substituting nucleotides derived from the acceptor end and variable pocket of tRNAPro for the corresponding nucleotides in a tRNAPhe gene, the identity of the resulting tRNA changed substantially but incompletely to that of tRNAPro. The redesigned tRNAPhe was weakly active and aminoacyl-tRNA was not detected. Ethyl methanesulfonate mutagenesis of the redesigned tRNAPhe gene produced a mutant with a wobble pair in place of a base pair in the end of the acceptor-stem helix of the transcribed tRNA. This mutant exhibited both a tRNAPro identity and substantial aminoacyl-tRNA. The results speak for the importance of a distinctive conformation in the acceptor-stem helix of tRNAPro for aminoacylation by the prolyl-tRNA synthetase. The anticodon also contributes to tRNAPro identity but is not necessary in vivo.

[Results of 35 ambulatory gamete transfers: evaluation of a successful method using regional anesthesia]

Thirty-five ambulatory gamete transfers were performed in 29 patients, resulting in a pregnancy rate of 40% and a take-home baby rate of 26%. Upon request 10 transfers in 9 patients were done under epidural anesthesia. The avoidance of general anesthesia allows the patient to consciously participate in her treatment and improves postoperative recovery. Our results suggest that gamete transfer procedures can be carried out under epidural anesthesia with no adverse effects on the pregnancy rate.

Detection of anti-Candida albicans IgE antibodies in vaginal washes from patients with acute vulvovaginal candidiasis

Vaginal washes from 55 women were investigated by means of an ELISA method for the presence of IgE antibodies against Candida albicans. These antibodies were detected in 87.1% of patients with clinical acute vulvovaginal candidiasis (group I), 100% of patients with suspected vulvovaginal candidiasis but negative by microscopy and culture (group II), 0% of asymptomatic carriers (group III) and 33.3% of uninfected controls (group IV). Statistically significant differences were observed comparing groups I and II vs. groups III and IV. The highest IgE vaginal antibody titers were mostly at the expense of serotype A C. albicans strains, which represented 83.3% of the C. albicans isolates. Non-C. albicans species also showed very low IgE levels. No correlation between serum and vaginal IgE was found. Furthermore, a second determination of vaginal IgE levels was performed in 3 patients. A decrease in IgE levels concomitant to a decline in clinical symptoms was observed in all of them after treatment.

Identification of p53 mutations by means of single strand conformation polymorphism analysis in gynaecological tumours: comparison with the results of immunohistochemistry

The tumour-suppressing gene p53 may undergo mutation by a variety of mechanisms, thus losing its tumour-suppressing activity, and ultimately behaving like an oncogene. The PAb 1801 monoclonal antibody is known to recognise both wild type and mutated p53, although in practice it seems to show a higher reactivity with the mutated gene product in several human tumours. We studied p53 overexpression in a series of 36 human tumours (17 mammary ductal infiltrating carcinomas, 11 endometrial carcinomas and 8 uterine cervical carcinomas) by means of immunohistochemistry using the PAb 1801 antibody and the streptavidin-biotin peroxidase technique. Furthermore, all tumours were screened for mutations in the "hot spot" regions of the p53 gene (exons 5 to 8) by means of SSCP (single strand conformation polymorphism) DNA analysis following amplification of the target exons using the polymerase chain reaction. A good correlation (75-100%) between positive immunohistochemistry and p53 mutations was observed in mammary and endometrial cancer, whereas mutations were detected in only two out of seven immunoreactive cervical carcinomas. Following these results, immunohistochemistry with the PAb monoclonal antibody may be safely used as a screening tool for the detection of mutated p53 in clinical samples of mammary and endometrial cancer, whereas it should be complemented with DNA analysis in cervix carcinoma.

Cardiopulmonary performance at rest and exercise after repair of total anomalous pulmonary venous connection

Although long-term evaluations of patients after repair of total anomalous pulmonary venous connection have generally shown them to be clinically asymptomatic, assessment of their cardiovascular and pulmonary systems have been limited. Residual cardiopulmonary abnormalities undetected at rest may result in impaired function during exercise. To evaluate this hypothesis 9 patients underwent exercise testing after repair of total anomalous pulmonary venous connection. Pulmonary function testing was performed before exercise. Patients exercised using a 1-minute incremental bicycle or treadmill protocol monitoring heart rate, oxygen consumption, carbon dioxide production and minute ventilation. Compared with healthy children, the study patients had reduced maximal oxygen consumption and reduced oxygen consumption at ventilatory anaerobic threshold. Chronotropic response was impaired in 5 patients. Resting pulmonary functions showed evidence of mild restrictive lung disease. Breathing reserve was within normal limits. It is concluded that (1) aerobic capacity is mildly reduced after repair of total anomalous pulmonary venous connection, (2) chronotropic impairment is a common occurrence, and (3) pulmonary testing suggests mild restrictive lung disease that does not compromise exercise performance.

Novel indolocarbazole protein kinase C inhibitors prevent reactivation of HIV-1 in latently infected cells

Suppression of human immunodeficiency virus-1 (HIV-1) reactivation in latently infected cells by protein kinase C (PKC) inhibitors has been described. Based on an initial finding with the indolocarbazole inhibitor Gö 6976 we have examined several members of this new class of potent and specific PKC inhibitors with respect to their ability to prevent the PKC-mediated induction of HIV-1 replication in the latently infected U1 cell line. Two of these compounds strongly inhibited not only PMA-induced release of p24-antigen and infectious virus particles into the supernatant (50% inhibition at 0.04-0.35 microM) but also TNF-alpha-mediated HIV-1 reactivation in the same concentration range. Significant lower toxicities compared to Gö 6976 were observed for the new compounds, with 50% cytotoxic concentrations at 5.2 microM for Gö 7775 and 3.4 microM for Gö 7716. This resulted in selectivity indices which were 10-20-times higher compared to the reference compound Gö 6976 and were comparable to those of registered anti-AIDS drugs. No anti-HIV-1 activity was observed for a closely related indolocarbazole analogue with no inhibitory activity in the PKC in vitro enzyme assay. This study demonstrates the important role of PKC in reactivation of HIV-1 in latently infected cells and points to the potential of indolocarbazoles to preserve the latent state of HIV-1 infection.

Subdural empyema of the cervical spine: clinicopathological correlates and magnetic resonance imaging. Report of three cases

A paucity of formally described information is available in the scientific literature regarding spinal subdural empyema. Patients presenting with neurological deterioration associated with subdural empyema are rarely identified, and treatment is often based upon anecdotal cases. The authors contribute three cases of primary cervical spinal subdural empyema and review the seven found in the literature. All patients had clinical evidence of neurological compromise, cervical tenderness, cervical pain, and leukocytosis upon admission. Cervical involvement ranged from C-2 to C-7. All patients underwent laminectomy with durotomy and drainage. The authors recommend prompt surgical decompressive laminectomy, copious irrigation, and drainage, followed with appropriate adjunctive antibiotic therapy for treatment of these patients.

[Myocardial protection: is retrograde equal to antegrade perfusion?]

The adequacy of retrograde delivery of cardioplegic solution to the right ventricle ist controversial. To evaluate this issue, we excised the plegic heart in 11 bovine experiments and infused an India ink solution (10 ml of India ink in 300 ml NaCl 0.9%) into the coronary sinus (n = 7) at a pressure of 60 cm H2O and into the aortic root (n = 4) at a pressure of 120 cm H2O. After fixation, the ventricles were cut in 11 transversal slices. The portion of coloured (= perfused) ventricular myocardium was calculated with computer-aided morphometric analysis. With antegrade infusion, 95 +/- 5% (mean +/- standard deviation) of the left ventricular volume (left ventricular free wall plus interventricular septum) was stained, with retrograde infusion 94 +/- 3%. Perfusion of the right ventricle was significantly lower with retrograde infusion (antegrade infusion 93 +/- 8%, retrograde 45 +/- 13%, p < 0.001), especially in the basal segments (basal vs. apical: 16 +/- 26% vs. 82 +/- 5%, p < 0.001). The adequate delivery of retrograde infusion to the left ventricle and septum allows good left ventricular myocardial protection with retrograde cardioplegia. Because the retrograde delivery to the right ventricle is markedly inadequate and nonuniform, the quality of right ventricular protection with retrograde cardioplegia has to be questioned.

Long-term results of tissue development and cell differentiation on Dacron prostheses seeded with microvascular cells in dogs

PURPOSE

The purpose of this study was to investigate in vivo the long-term development, differentiation, and proliferation of the subendothelial tissue on Dacron prostheses seeded with microvascular cells (MVC).

METHODS

Autologous MVC from omental adipose tissue were seeded on 4 mm Dacron prostheses and the prostheses interposed in the carotid arteries of mongrel dogs for 5, 13, and 26 weeks.

RESULTS

Light and electron microscopic evaluation of patent seeded prostheses demonstrated an almost complete monolayer of endothelial cells and well-organized subendothelial tissue, whereas patent control prostheses were mainly covered by red and white thrombi, which were partially replaced by organized tissue with increased implantation time. The measurements of the thickness of the luminal cell layer in seeded and control grafts showed no statistically significant increase between 5 and 26 weeks of implantation. The subendothelial tissue of seeded prostheses demonstrated a time-dependent maturation of highly synthesizing myofibroblasts embedded in a collagen matrix to cells with features of smooth muscle cells located in a collagen-elastin matrix. In control grafts examined after 26 weeks the spontaneous endothelialization was accompanied by a delayed or incomplete maturation of subendothelial tissue.

CONCLUSIONS

Our study indicates that MVC seeded onto Dacron prostheses are able to generate a vascular wall that does not continue to proliferate after prolonged implantation and that increasingly resembles the wall of a normal artery in cell differentiation and intercellular matrix.

High-intensity chemotherapy with hematopoietic support in breast cancer

Chemotherapy can produce excellent palliation for many patients with metastatic breast cancer. Survival impact is, however, limited, and permanent remission is extremely rare. There is increasing evidence that dose and dose intensity may be important determinants of outcome in the chemotherapy of breast cancer. Single courses of chemotherapy in doses requiring autologous bone marrow support produce high rates of objective response in patients with metastatic disease that was refractory to prior standard-dose therapy. When used as first chemotherapy for metastases or as consolidation in patients whose disease is responding to lower-dose therapy, high-dose chemotherapy can result in prolonged disease-free survival for some patients. The major cause of treatment failure is relapse from a chemotherapy-induced complete response. Kinetic models suggest that multiple, rapidly cycled courses of high-dose chemotherapy might be superior to single applications or to multiple treatments that are widely spaced in time. Heretofore, the substantial toxicity of high-dose chemotherapy (up to 20% mortality in some early trials) has largely precluded the consideration of timely retreatment; however, the risk appears to have been reduced through the use of hematopoietic growth factors and peripheral blood progenitor cells. Our group has used these new technologies to develop regimens consisting of multiple cycles of high-dose chemotherapy that are rapidly administered. We are currently refining these regimens in preparation for phase II and III studies.

[Morphological basis of atherosclerosis]

The lesions of atherosclerosis are initiated as a response to some form of injury to arterial endothelium. Increase in plasma levels of low-density lipoproteins or some components of hyperlipidemic serum may increase the rate of penetration into the artery wall. Monocytes adhere to endothelium, emigrate into the intima and transform into lipid-laden macrophages. The second component of atherogenesis is smooth muscle proliferation in the intima. The proliferating cells originate from cells migrating from the media and from myointimal cells. After adhesion to foci of injury, platelets release platelet-derived growth factor, a potent mitogen for intimal smooth muscle cells. The plaque is increasing, the lumen narrowing. A plaque consisting mainly of yellow, grumous fluid is called an atheroma. The oily content of this plaque is covered by a fibrous cap that is often thin and prone to rupture. An occluding thrombus may result. Lipids and crystalline cholesterol initiate a foreign-body reaction, an inflammatory process. Older lesions are calcified. Examples from the daily work in the mortuary demonstrate the pathogenetic relevance of hypertension, thrombocytes and endothelium.

[Comparison of vaginal and abdominal ultrasound measurements with embryologic growth curves in early pregnancy]

Body lengths and chorionic diameters of 225 early pregnancies with known fertilisation age, measured by transvaginal sonography (TVS), were compared with measuring results of measurements from abdominal ultrasound and of embryological specimen from the literature. The TVS measuring results were made according to the Carnegie classification. It is shown that the growth curve obtained by TVS is very similar to valid embryological growth curves, although the "Greatest Length" (GL) is measured by sonography not the Crown-Rump-Length (CRL). Between the sixth and eighth gestational week, the TVS curve shows strong resemblance to abdomino-sonographical curves. After that period, the TVS results tend to be systematically lower. The earliest TVS measurement of the human embryo in possible in the sixth gestational week, one week earlier than with abdominal ultrasound. There is a good correlation between the development of a structure and its earliest detection by TVS, active movements of the embryo can even be shown earlier than assumed by embryologists (stage 20/ninth week of gestation). Due to terminological reasons, in ultrasound the established term "Crown-Rump-Length" should be replaced by "Greatest Length". In a TVS-examination of an embryo (gestational weeks 4 to 11), morphological criteria must be additional contributions to the determination of maturity and integrity of a pregnancy. The application of the specimen-derived Carnegie classification to TVS measurements seem to be possible, as well as the utilization of TVS results in embryology.

Fibrin-specific lysis of microthrombosis in endotoxemic rats by saruplase

The dissolution by the fibrinolytic agent saruplase of microthrombi due to disseminated intravascular coagulation (DIC) has been studied in anesthetized rats. The intravenous infusion of E. coli lipopolysaccharide (endotoxin) for 4 hours (total dose: 25 mg/kg) induced marked thrombocytopenia and hypofibrinogenemia. DIC-related microthrombosis, detected as increased deposition of 125I-labelled human fibrin, was found in the liver and the kidneys, but not in the lungs, the heart, the mesenterium, the spleen and the M. rectus abdominis of endotoxemic rats. Treatment with 1-20 micrograms/kg.min saruplase, that was infused concomitantly with endotoxin, dose-dependently and significantly reduced endotoxin-induced microthrombosis in the liver and the kidneys by 85 resp. 88%. When saruplase (20 micrograms/kg.min) was administered only during the last two hours of endotoxin infusion, liver microthrombosis was still significantly dissolved by 69%, whereas renal microthrombosis was insignificantly reduced by 34%. The inhibition of endotoxin-induced microthrombosis took place in the same dosage range as the shortening of the euglobulin clot lysis time in normal rats by saruplase as a measure of its fibrinolytic activity. Saruplase did not modify thrombocytopenia and hypofibrinogenemia in endotoxemic rats. Saruplase per se did not affect plasma fibrinogen levels. Thus, in a fibrin-selective dose range saruplase is able to dissolve microthrombosis associated with DIC in endotoxemic rats.

Paraanastomotic aneurysms of the abdominal aorta

PURPOSE

Aneurysm formation after abdominal aortic bypass reconstruction is an infrequent but underestimated complication. Aneurysms may occur after aortic prosthetic reconstruction for both occlusive and aneurysmal disease, may occur early or late, and may be classified as a pseudoaneurysm or true aneurysm.

METHODS

Thirty-one cases in 29 patients treated at a tertiary referral center from 1980 to 1992 were retrospectively reviewed. Iliac and femoral aneurysms were excluded. The indication for initial abdominal aortic grafting had been aneurysmal disease in 19 patient and occlusive disease in 10 patients.

RESULTS

There were 25 pseudoaneurysms and six true aneurysms, the latter followed grafting for aneurysmal disease. The current aneurysm (mean size 7.1 cm) was at the proximal aortic anastomosis in 27 cases and at the distal aortic anastomosis in two cases. Symptoms at presentation included abdominal pain (14), mass (12), claudication (9), back pain (6), and gastrointestinal bleeding (3). Surgical management included interposition tube grafting (16), aortoiliofemoral bypass (9), and graft removal with extraanatomic bypass (3). The overall operative morbidity rate was 73%, and mortality rate was 21%.

CONCLUSIONS

Paraanastomotic aortic aneurysms are being increasingly recognized and are associated with high morbidity and mortality rates. Patients should be periodically studied after aortic grafting with abdominal ultrasonography for early detection of this potentially serious complication. Elective surgical repair is advocated in the effort to minimize morbidity rates.