Intraoperative study of polarization and evoked response signals in different endocardial electrode designs

Some new generation pacemakers use an algorithm based on evoked response (ER) detection to verify beat-to-beat capture and to enable automatic adjustment of output. This is a prospective acute study of polarization signal (PS) and ER in nine currently available electrodes. Intraoperative testing of ventricular bipolar electrodes used the Autocapture (AC) algorithm. The intrinsic R wave, PS, ER, acceptance of AC function, and stimulation thresholds (STs) were obtained. Ventricular electrodes were categorized as follows: titanium nitride (TiN)-coated passive and active fixation, high impedance (HI), passive fixation (VP), iridium oxide-coated titanium (IROX) (VI), and platinum helix (PH) active fixation. Acute testing was performed in 217 patients with an average age of 74.26 years, 59.6% were men with primary pacing indication-SSS (46.3%). There were no significant differences found with respect to R wave and threshold between the various electrodes. PH active-fixation electrodes had significantly higher ER and PS than other groups including the TiN-coated active-fixation electrodes. TiN-coated electrodes (active and passive fixation) had significantly lower PS than other electrodes. As a result, TiN electrodes had a significantly higher functional rate of AC (91.7%), whereas PH had the lowest rate (0%). In conclusion, (1) polarization characteristics are significantly different for commercially available ventricular electrodes, (2) certain physical features at the tissue to electrode interface like TiN coating appears to be more important in determining PS than electrode tip size and fixation method, and (3) the current algorithm for AC requires electrodes that provide low polarization for satisfactory performance.

Perinatal exposure to polychlorinated biphenyls Aroclor 1016 or 1254 did not alter brain catecholamines nor delayed alternation performance in Long-Evans rats

Several reports have indicated that polychlorinated biphenyls (PCB) altered development of biogenic amine systems in the brain, impaired behavioral performances, and disrupted maturation of the thyroid axis. The current study examines whether these developmental effects of PCB are correlated. Timed-pregnant Long-Evans rats were gavaged with the PCB mixture Aroclor 1016 (A-1016, 10 mg/kg) from gestation day (GD) 6 to parturition. Some pups continued to receive daily oral administration of PCB (10 mg/kg) until weaning at postnatal day (PD) 21. Another group of pregnant rats was given Aroclor 1254 (A-1254, 8 mg/kg) daily from GD 6 to weaning. At various age intervals, rats were sacrificed and six brain regions (prefrontal cortex, striatum, hippocampus, diencephalon, cerebellum, midbrain + brain stem) were removed and analyzed for dopamine (DA) and norepinephrine (NE) levels by high-performance liquid chromatography. In addition, transmitter turnover rates were determined after an acute treatment of alpha-methyl-p-tyrosine. Serum samples were collected and analyzed for triiodothyronine (T(3)) and thyroxine (T(4)) by radioimmunoassay. Behaviorally, rats were evaluated for spatial learning and memory by means of T-maze delayed alternation and Morris maze tasks on PD 23 and PD 70, respectively. A-1016 treatment produced only small and transient reductions in body weight gain, and generally did not alter the thyroid status of the developing rats. It did not cause any significant changes in DA or NE level, or turnover rate in any of the brain regions examined, nor did it affect behavioral measures of cognitive development. In contrast, perinatal exposure to A-1254 led to marked deficits of growth, and sharply reduced serum T(4), although T(3) remained largely unaffected. Accompanying this hormonal imbalance, brain NE contents in the A-1254-exposed pups were reduced, although brain DA was not significantly affected; no demonstrable neurobehavioral deficits were seen in the T-maze or Morris maze tests. These results indicated that development of central noradrenergic neurons was compromised by perinatal exposure to A-1254 but not A-1016, and both PCB mixtures failed to alter behavioral performances.

Quantitative evaluation of infant's nonnutritive and nutritive sucking

Two important aspects of the clinical feeding evaluation of infants are the assessment of their nonnutritive and nutritive sucking skills. Nonnutritive sucking is monitored routinely by using a gloved finger and nutritive sucking by observing infants' sucking while bottle feeding. This approach, however. provides only a subjective and descriptive evaluation. In this study, we developed a finger pressure device that allows for quantification of specific measures of nonnutritive sucking. We are proposing that its use, in combination with the nipple/bottle system developed for the monitoring of nutritive sucking. will allow therapists to conduct objective and quantitative evaluations of infants' nonnutritive and nutritive sucking. The suction and expression components of sucking are monitored via two catheters placed at the tip of the index finger of a disposable glove and at the tip of a bottle nipple. The observations made from the standard clinical feeding evaluation and from these two instruments were compared. In addition to providing quantitative measures of sucking, the latter techniques allowed the review/reassessment of data, the monitoring of the maturation of oral motor skills over time, and the comparison of these measures between infants. It is proposed that the concurrent use of these devices will allow therapists to conduct more objective and detailed evaluations of infants' feeding skills than can be obtained at present.

Serum vascular endothelial growth factor predicts venous invasion in hepatocellular carcinoma: a prospective study

OBJECTIVE

To evaluate the correlation between serum vascular endothelial growth factor (VEGF) level and the clinicopathologic features in patients with hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

VEGF is an important angiogenic factor regulating tumor angiogenesis. A high serum VEGF level has been shown to be associated with tumor progression and metastasis in several human cancers, but its significance in HCC is unclear. The correlation between serum VEGF level and tumor pathologic features in patients with HCC has not been studied before.

METHODS

Preoperative serum samples and tumor specimens were prospectively collected in 100 patients undergoing resection of HCC. Serum VEGF level was measured by enzyme-linked immunosorbent assay, and tumor VEGF expression was assessed by immunohistochemical study. Histopathologic examination was performed by a pathologist without prior knowledge of the serum VEGF level or tumor VEGF expression.

RESULTS

Preoperative serum VEGF levels ranged from 15 to 1,789 pg/mL (median 269). When serum VEGF levels were compared between groups categorized by different clinicopathologic variables, significant correlation was found between a high serum VEGF level and absence of tumor capsule, presence of intrahepatic metastasis, presence of microscopic venous invasion, and advanced stage. There was a positive correlation between the serum VEGF level and tumor expression of VEGF as well as platelet count. When the 75th percentile serum VEGF level (500 pg/mL) was used as a cutoff level, the frequency of venous invasion in patients with a high serum VEGF level was significantly greater compared with patients with a low serum VEGF level. By multivariate analysis, a serum VEGF level of more than 500 pg/mL and tumor size more than 5 cm were independent preoperative factors predictive of microscopic venous invasion. During a median follow-up of 11.6 months, 48% of patients with a serum VEGF level of more than 500 pg/mL and 27% of those with a serum VEGF level of 500 pg/mL or less developed postoperative recurrence.

CONCLUSIONS

These results show that a high preoperative serum VEGF level is a predictor of microscopic venous invasion in HCC, suggesting that the serum VEGF level may be useful as a biologic marker of tumor invasiveness and a prognostic factor in HCC.

p15(PAF), a novel PCNA associated factor with increased expression in tumor tissues

Proliferating cell nuclear antigen (PCNA) is an essential protein in both DNA replication and DNA damage repair. A novel 15 kD protein, p15(PAF), was identified as a PCNA-associated factor in a yeast two-hybrid screen using PCNA as the bait. p15(PAF) is localized primarily in the nucleus. p15(PAF) shares the conserved PCNA binding motif with several other PCNA binding proteins including CDK inhibitor p21. Overexpression of p15(PAF) competes with p21-PCNA binding. Mutation of this motif in p15(PAF) abolished its PCNA-binding activity. Notably, p15(PAF) expression in several types of tumor tissues was significantly increased, especially in esophageal tumors. Like PCNA, p15(PAF) may possess prognostic significance in a broad array of human cancers.

Toward a biologically based dose-response model for developmental toxicity of 5-fluorouracil in the rat: acquisition of experimental data

Biologically based dose-response (BBDR) models represent an emerging approach to improving the current practice of human health-risk assessment. The concept of BBDR modeling is to incorporate mechanistic information about a chemical that is relevant to the expression of its toxicity into descriptive mathematical terms, thereby providing a quantitative model that will enhance the ability for low-dose and cross-species extrapolation. Construction of a BBDR model for developmental toxicity is particularly complicated by the multitude of possible mechanisms. Thus, a few model assumptions were made. The current study illustrates the processes involved in selecting the relevant information for BBDR modeling, using an established developmental toxicant, 5-fluorouracil (5-FU), as a prototypic example. The primary BBDR model for 5-FU is based on inhibition of thymidylate synthetase (TS) and resultant changes in nucleotide pools, DNA synthesis, cell-cycle progression, and somatic growth. A single subcutaneous injection of 5-FU at doses ranging from 1 to 40 mg/kg was given to pregnant Sprague-Dawley rats at gestational day 14; controls received saline. 5-FU was absorbed rapidly into the maternal circulation, and AUC estimates were linear with administered doses. We found metabolites of 5-FU directly incorporated into embryonic nucleic acids, although the levels of incorporation were low and lacked correlation with administered doses. On the other hand, 5-FU produced dose-dependent inhibition of thymidylate synthetase in the whole embryo, and recovery from enzyme inhibition was also related to the administered dose. As a consequence of TS inhibition, embryonic dTTP and dGTP were markedly reduced, while dCTP was profoundly elevated, perhaps due to feedback regulation of intracellular nucleotide pools. The total contents of embryonic macromolecules (DNA and protein) were also reduced, most notably at the high doses. Correspondingly, dose-related reductions of fetal weight were seen as early as GD 15, and these deficits persisted for the remainder of gestation. These detailed dose-response parameters involved in the expression of 5-FU developmental toxicity were incorporated into mathematical terms for BBDR modeling. Such quantitative models should be instrumental to the improvement of high-to-low dose and cross-species extrapolation in health-risk assessment.

Toward a biologically based dose-response model for developmental toxicity of 5-fluorouracil in the rat: a mathematical construct

Biologically based dose-response (BBDR) models comprise one way to incorporate mechanistic information into a dose-response assessment to be used for risk assessments. The chemotherapeutic drug 5-fluorouracil (5-FU) has been used as a prototypic compound for the construction of a BBDR model for developmental toxicity. Previous work has provided data and a general mechanistic framework for the developmental toxicity of 5-FU when it was administered to pregnant rats subcutaneously on gestation day 14. In this paper, a mathematical model relating maternally administered treatment with 5-FU to embryonal thymidylate synthetase inhibition and thymidylate synthetase inhibition to various measures of deoxyribonucleotide triphosphate (dNTP) pool perturbation is developed, and parameters are estimated using the data collected. The strategy used was to develop semi-empirical submodels for each of the intervening steps, and to estimate model parameters from previously described data. The models developed predict that there is no practical threshold for dNTP pool perturbation; that is, even minimal doses of 5-FU should result in some perturbation of dNTP pools. In particular, the relationship between dNTP pool perturbation and fetal weight deficit suggests that if there is a biological threshold for the effect of 5-FU on fetal weight, the responsible repair or compensation mechanism must be downstream of dNTP pool perturbation, and saturable at 5-FU doses lower than 10 mg/kg (the lowest dose examined for developmental effects in these studies).

First results of the Canadian and European Single lead DDD Studies. A report of two multicenter studies on Vena Cava Atrial Stimulation (VECATS)

The first results of a new, single lead DDD pacing system consisting of two bipolar combinations of floating atrial ring electrodes, with the proximal ring at the vena cava superior junction, and which can be used separately for atrial sensing and pacing (VECATS) are reported. Uncomplicated implantation of the pacing system was performed in 78 patients with VDD indications. Pacing and sensing parameters were measured at implantation, before discharge (days 1-3), at 1 and 3 months in various positions and during activity. Atrial pacing threshold (AT) and diaphragmatic stimulation threshold (DT) were 3.3 +/- 1.1 V and 7.2 +/- 2.2 at implant, and 4.3 +/- 0.5 and 7.9 +/- 1.1 V at 3 months, respectively, in the European group. In the Canadian group AT increased and DT decreased during follow-up, leaving a safety margin of 1 V. Reliable intraoperative atrial pacing was possible in 93% of patients. Failures were caused by no capture (3%) or AT > DT (4%). At 3 months, 54% of the atria were consistently paced. Atrial pacing failures were due to no atrial capture (8%), and AT > DT (38%). We conclude that atrial pacing was safe and initially possible in the majority of patients with the VECATS pacing system, though diaphragmatic stimulation became more prevalent over time, due to an increase in AT threshold and a decrease in DT.

Non-steroidal anti-inflammatory drug toxicity in the upper gastrointestinal tract

Non-steroidal anti-inflammatory drug (NSAID) toxicity in the upper gastrointestinal tract is the most common serious drug-induced toxicity reported to drug regulatory authorities. In the last two decades, the rediscovery of H. pylori, development of potent ulcer-healing drugs and specific Cox-II inhibitors have opened new horizons in the management of NSAID toxicity. A Working Party composed of gastroenterologists and rheumatologists in the Asia-Pacific region met in Cairns, Australia, in 1999 to review the literature and develop appropriate guidelines. Recommendations were made based on the latest existing evidence. The importance of clinical events as study endpoints was emphasized. While differences exist between NSAIDs and aspirin, most studies have shown that advanced age, history of peptic ulcer disease, serious concomitant illnesses and coprescription of NSAID/aspirin with anticoagulants and steroids are high risk factors. These patients should be considered for prophylactic anti-ulcer therapy. Helicobacter pylori infection may aggravate the toxicity of NSAIDs and, in selected cases, should be treated before NSAID/aspirin is prescribed. Proton pump inhibitors and misoprostol are the most promising agents in preventing gastric and duodenal ulcers. When NSAID/aspirin needs to be continued in patients who develop an NSAID-related ulcer, proton pump inhibitors offer the best healing effect. With the discovery of cyclo-oxygenase isoforms (Cox-I and Cox-II), preferential and specific Cox-II inhibitors have been developed. While early clinical data have suggested promising antiinflammatory effects and improved safety profile in the gastrointestinal tract, several key issues on long-term safety remain unresolved. The use of potent anti-ulcer therapy, treatment of H. pylori infection and the development of Cox-II inhibitor will change the scenario of NSAID/aspirin-related gastrointestinal toxicity in the next millennium.

Identification of a GA-rich sequence as a protein-binding site in the 3'-untranslated region of chicken elastin mRNA with a potential role in the developmental regulation of elastin mRNA stability

Synthesis of aortic elastin peaks in the perinatal period and then is strongly down-regulated with postnatal development and growth. Decreased stability of elastin mRNA contributes to this developmental decrease in chick aortic elastin production. We have previously shown that destabilization of elastin mRNA is correlated with decreased binding of cytosolic protein(s) to a large, GC-rich region of secondary structure in the 3'-untranslated region (3'-UTR) of elastin mRNA. In this study, using gel migration shift assays, deletion constructs, and antisense competition assays, we identify a major protein-binding site in the 3'-UTR of elastin as a GA-rich sequence (UGGGGGGAGGGAGGGAGGGA), which we have designated the G3A motif. This motif is present in the 3'-UTR of elastin from several species. Binding proteins are present in both nuclear and cytoplasmic extracts, and their abundance is associated with tissues producing elastin and correlated with circumstances in which elastin mRNA is stable. These results suggest that the conserved GA-rich sequence of the elastin 3'-UTR is an important element in the regulation of stability of the elastin mRNA.

A review of antimycobacterial natural products

Tuberculosis is a chronic infectious disease caused by several species of mycobacteria. Due to multi-drug resistant strains of mycobacteria and to a high prevalence of tuberculosis in patients who have acquired human immunodeficiency syndrome (AIDS), the number of patients infected with the disease is increasing worldwide. Thus there is an urgent need for new effective antimycobacterial agents to replace those currently in use. In this instance, the plant kingdom is undoubtedly a valuable source for new anti-tuberculosis agents. The present review article reports the findings from an extensive literature search of all plants that have been assessed for antimycobacterial/antitubercular activity over the past 20-30 years. An attempt has been made to summarize the information in order to highlight those promising plant species which are worthy of further investigation as leads for drug development. Over 350 plant species from a wide range of families and origins, containing various chemical classes of compounds, have been screened for such activity. A review of the relevant in vitro assays using different species of pathogenic and non-pathogenic mycobacteria is also included.

Characterization of the developmental stages of sucking in preterm infants during bottle feeding

It is acknowledged that the difficulty many preterm infants have in feeding orally results from their immature sucking skills. However, little is known regarding the development of sucking in these infants. The aim of this study was to demonstrate that the bottle-feeding performance of preterm infants is positively correlated with the developmental stage of their sucking. Infants' oral-motor skills were followed longitudinally using a special nipple/bottle system which monitored the suction and expression/compression component of sucking. The maturational process was rated into five primary stages based on the presence/absence of suction and the rhythmicity of the two components of sucking, suction and expression/compression. This five-point scale was used to characterize the developmental stage of sucking of each infant. Outcomes of feeding performance consisted of overall transfer (percent total volume transferred/volume to be taken) and rate of transfer (ml/min). Assessments were conducted when infants were taking 1-2, 3-5 and 6-8 oral feedings per day. Significant positive correlations were observed between the five stages of sucking and postmenstrual age, the defined feeding outcomes, and the number of daily oral feedings. Overall transfer and rate of transfer were enhanced when infants reached the more mature stages of sucking. We have demonstrated that oral feeding performance improves as infants' sucking skills mature. In addition, we propose that the present five-point sucking scale may be used to assess the developmental stages of sucking of preterm infants. Such knowledge would facilitate the management of oral feeding in these infants.

A cardiac evoked response algorithm providing threshold tracking: a North American multicenter study. Clinical Investigators of the Microny-Regency Clinical Evaluation Study

The purpose of this study was to evaluate a pacing system using the recognition of cardiac evoked response for the automatic adjustment of pacing output. Patients were prospectively followed after primary implantation of VVIR pacemakers using AutoCapture (St. Jude Medical CRMD). Sensing and pacing thresholds, polarization signal, evoked response, and AutoCapture performance were evaluated with serial visits and 24-hour Holter monitoring. Three hundred ninety-eight patients (mean age 71 +/- 15 years) were followed for an average duration of 1 year (3 days-1.75 years) with the algorithm functional in > 90% of patients. Backup pacing in the event of exit block was confirmed in all patients. Pacing thresholds remained stable at 0.89 +/- 0.34 V with a pulse width of 0.31 ms (with chronic output autoset at 0.3 V above the actual threshold). Evoked response exhibited a small but statistically significant increase with time (8.92 mV at implant, 9.60 mV at 12 months), however, this finding did not result in any change in AutoCapture function during our follow-up period. The polarization signal remained stable with minimal variation (1.12 mV at implant, 1.18 at 12 months). No clinical adverse events were observed using the AutoCapture algorithm. In this initial experience with the AutoCapture algorithm the evoked response and polarization measurements remained adequate, allowing the system to function in the majority of patients with safe, low output pacing. High energy backup pacing provided an added safety feature over fixed output devices in cases of unexpected threshold rises. Longer follow-up is required for continued long-term validation of the algorithm.

Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes. Canadian Trial of Physiologic Pacing Investigators

BACKGROUND

Evidence suggests that physiologic pacing (dual-chamber or atrial) may be superior to single-chamber (ventricular) pacing because it is associated with lower risks of atrial fibrillation, stroke, and death. These benefits have not been evaluated in a large, randomized, controlled trial.

METHODS

At 32 Canadian centers, patients without chronic atrial fibrillation who were scheduled for a first implantation of a pacemaker to treat symptomatic bradycardia were eligible for enrollment. We randomly assigned patients to receive either a ventricular pacemaker or a physiologic pacemaker and followed them for an average of three years. The primary outcome was stroke or death due to cardiovascular causes. Secondary outcomes were death from any cause, atrial fibrillation, and hospitalization for heart failure.

RESULTS

A total of 1474 patients were randomly assigned to receive a ventricular pacemaker and 1094 to receive a physiologic pacemaker. The annual rate of stroke or death due to cardiovascular causes was 5.5 percent with ventricular pacing, as compared with 4.9 percent with physiologic pacing (reduction in relative risk, 9.4 percent; 95 percent confidence interval, -10.5 to 25.7 percent [the negative value indicates an increase in risk]; P=0.33). The annual rate of atrial fibrillation was significantly lower among the patients in the physiologic-pacing group (5.3 percent) than among those in the ventricular-pacing group (6.6 percent), for a reduction in relative risk of 18.0 percent (95 percent confidence interval, 0.3 to 32.6 percent; P=0.05). The effect on the rate of atrial fibrillation was not apparent until two years after implantation. The observed annual rates of death from all causes and of hospitalization for heart failure were lower among the patients with a physiologic pacemaker than among those with a ventricular pacemaker, but not significantly so (annual rates of death, 6.6 percent with ventricular pacing and 6.3 percent with physiologic pacing; annual rates of hospitalization for heart failure, 3.5 percent and 3.1 percent, respectively). There were significantly more perioperative complications with physiologic pacing than with ventricular pacing (9.0 percent vs. 3.8 percent, P<0.001).

CONCLUSIONS

Physiologic pacing provides little benefit over ventricular pacing for the prevention of stroke or death due to cardiovascular causes.

Glucocorticoid receptor regulation in the rat embryo: a potential site for developmental toxicity?

Glucocorticoids play a key role in controlling numerous cellular processes during embryogenesis and fetal development. Excess glucocorticoids during development have been linked to dysmorphogenesis and/or intrauterine growth impairment in rodents. The actions of glucocorticoids are mediated by interaction with their receptors. Negative feedback regulation of glucocorticoid receptor (GR) is important for limiting cellular sensitivity to the hormones. Hence, acute exposure of the adult rat to the synthetic glucocorticoid dexamethasone (DEX) reduced both GR mRNA and protein in a variety of tissues that include hippocampus and liver, in a dose- and time-dependent fashion. Reduction in GR mRNA and protein were observable when DEX was given repeatedly at doses as low as 0. 05 mg/kg. In the control whole rat embryo, GR mRNA was low but measurable at as early as gestational day (GD) 10, but underwent rapid ontogenetic increase in the ensuring days. In contrast to the adult, neither GR mRNA nor protein in the whole rat embryo was affected by acute or repeated DEX administration to pregnant rats on GD10-13, even at doses as high as 0.8 mg/kg. Similar results were obtained in embryonic palate and liver, tissues known to be glucocorticoid targets. These data suggest that GR autoregulation does not occur during organogenesis in the rat. Accordingly, hormonal elevations from stress or chemical insults can be transduced unrestrictedly, ultimately leading to aberrant cell function and development. The unique mode of GR regulation seen in the embryonic cells may provide a potential common mechanism for developmental perturbation and toxicity for a variety of insults.

Evaluation of biologically based dose-response modeling for developmental toxicity: a workshop report

Biologically based dose-response (BBDR) modeling represents a novel approach for quantitative assessment of health risk by incorporating pharmacokinetic and pharmacodynamic characteristics of a chemical and by relating the immediate cellular responses to a cascade of aberrant biological actions that leads to detectable adverse outcomes. The quantitative relationship of each of the intervening events can be described in mathematical forms that are amenable for adjustment and extrapolation over a range of doses and across species. A team of investigators at the Reproductive Toxicology Division of the U.S. Environmental Protection Agency has explored the feasibility of BBDR modeling by examining the developmental toxicity of a known teratogen, 5-fluorouracil. A panel of researchers from academic and industrial laboratories, biomathematical modelers, and risk assessment scientists was convened in a workshop to evaluate the approaches undertaken by the EPA team and to discuss the future prospects of BBDR modeling. This report summarizes the lessons learned from one approach to BBDR modeling and comments from the panelists: while it is possible to incorporate mechanistic information into quantitative dose-response models for the assessment of health risks, the process is enormously data-intensive and costly; in addition, the confidence of the model is directly proportional to our current understanding of basic biology and can be enhanced only through the ongoing novel discoveries. More importantly, the extent of "uncertainty" (inherent with the default assumptions associated with the NOAEL or benchmark approach) reducible by BBDR modeling requires further scrutiny and comparison.

Oral feeding in premature infants: advantage of a self-paced milk flow

An earlier study demonstrated that oral feeding of premature infants (<30 wk gestation) was enhanced when milk was delivered through a self-paced flow system. The aims of this study were to identify the principle(s) by which this occurred and to develop a practical method to implement the self-paced system in neonatal nurseries. Feeding performance, measured by overall transfer, duration of oral feedings, efficiency, and percentage of successful feedings, was assessed at three time periods, when infants were taking 1-2, 3-5, and 6-8 oral feedings/day. At each time period, infants were fed, sequentially and in a random order, with a self-paced system, a standard bottle, and a test bottle, the shape of which allowed the elimination of the internal hydrostatic pressure. In a second study, infants were similarly fed with the self-paced system and a vacuum-free bottle which eliminated both hydrostatic pressure and vacuum within the bottle. The duration of oral feedings, efficiency, and percentage of successful feedings were improved with the self-paced system as compared to the standard and test bottles. The results were similar in the comparison between the self-paced system and the vacuum-free bottle. Elimination of the vacuum build-up naturally occurring in bottles enhances the feeding performance of infants born <30 wk gestation as they are transitioned from tube to oral feeding. The vacuum-free bottle is a tool which caretakers can readily use in neonatal nurseries.

Feeding tolerance in premature infants fed fortified human milk

BACKGROUND

To evaluate feeding tolerance in premature infants immediately after the addition of human milk fortifier (HMF) to their expressed human milk diet.

METHODS

Data on milk intake, feeding tolerance, and related assessments and growth milestones from a prospective study of feeding strategies in premature infants were analyzed. The database was searched for the first day HMF was added to the feeding of infants receiving human milk exclusively. The following assessments were tabulated for the 5 days before and the 5 days after the addition of HMF: milk intake, the number of episodes of abdominal distension, gastric residual volume (GRV) more than 2 ml/kg and more than 50% of the volume fed in the prior 3 hours. bile-stained gastric residual, emesis or regurgitation, blood in the stool, the number of abdominal radiographs, the number of episodes of apnea and bradycardia, changes in findings in the clinical examination, and the number of hours feeding was withheld. The time to achieve full tube feeding, complete oral feeding, and hospital discharge were recorded.

RESULTS

Seventy-six exclusively human milk-fed premature infants (birth weight, 1065+/-18 g; gestational age, 27+/-0.1 weeks; mean +/- SEM) who received HMF beginning 22+/-0.8 days of age were evaluated. There were significant increases in milk intake and in the number of episodes of GRV more than 2 ml/kg and emesis after the addition of HMF. There were no differences in the number of hours feeding was withheld or any other assessment after the addition of HMF. Infants with increases in GRV more than 2 ml/kg and/or emesis after the addition of HMF were not more likely to be delayed in the time to achieve full tube feeding, complete oral feeding, or hospital discharge than infants who did not experience these events.

CONCLUSION

These data suggest that, when all feeding and related assessments and the time to achieve important growth milestones are considered, the addition of HMF does not adversely affect the outcome of the premature infant.

Role of endothelium in thapsigargin-induced arterial responses in rat aorta

We assessed the role of endothelium in the arterial response to thapsigargin, the Ca(2+)-ATPase inhibitor of the endoplasmic reticulum, in rat isolated aortic rings. Thapsigargin induced an endothelium-dependent relaxation of phenylephrine-contracted aortic rings with an EC(50) of 2.6+/-0.4 nM and a 75% maximum relaxation, while it was less effective against 30 mM K(+)-induced contraction. Pretreatment of aortic rings with N(G)-nitro-L-arginine methyl ester (30 microM) or methylene blue (1 microM) reduced thapsigargin-induced relaxation by approximately 85%. Thapsigargin failed to relax the endothelium-denuded rings. L-Arginine (3 mM) partially, but significantly, antagonized the effect of 30 microM N(G)-nitro-L-arginine methyl ester. Pretreatment with indomethacin (3 microM), glibenclamide (1 microM) or iberiotoxin (100 nM) did not alter the thapsigargin-induced relaxation. In contrast, pretreatment with tetrapentylammonium ions (TPA(+), 1-3 microM) or with 300 microM Ba(2+) suppressed the relaxant response to thapsigargin. TPA(+) (3 microM) also attenuated acetylcholine-induced relaxation. Thapsigargin-induced endothelium-dependent relaxation was primarily dependent on the presence of extracellular Ca(2+). Interestingly, when the tissues were exposed to very low concentrations of thapsigargin (1-3 nM) the nitric oxide-dependent relaxation induced by acetylcholine or A23187 was markedly reduced. While thapsigargin (3 nM) did not influence the relaxation induced by endothelium-independent dilators, sodium nitroprusside and verapamil. These results indicate that thapsigargin produced complex vascular effects primarily by acting on the endothelial cells. Thapsigargin causes an endothelial nitric oxide-dependent relaxation; on the other hand, it inhibits nitric oxide-mediated relaxation at the similar concentrations. Activation of TPA(+)- and Ba(2+)-sensitive but not Ca(2+)-activated or ATP-sensitive K(+) channels may be also involved in thapsigargin-induced relaxation of rat isolated aortic rings.

Biologically based risk assessment models for developmental toxicity

It is obvious that the task of incorporating mechanistic information into dose-response assessment for developmental toxicity is, by and large, still at its conceptual stage. Our immature understanding of embryogenesis and teratogenesis forces us to make simplifying biological assumptions that may turn out to be erroneous; therefore, these mechanistically based models should be constructed so as to be easily modified as new information becomes available. The data-intensive (and costly) nature of these modeling efforts may also limit their practice to extraordinary situations where, for instance, large segments of the human population are exposed to low levels of a compound and the determination of a safe level of exposure is of utmost importance, or where compounds are of such immense economic or therapeutic value that their use would warrant a concerted effort to minimize the uncertainties inherent in the current methods of extrapolation. Nevertheless, this chapter has presented several attempts to translate the concept of BBDR into practice. When these applications become successful, these models should provide risk assessors with more reliable response indicators at low doses (where human exposures are realistic) and more accurate cross-strain/cross-species comparisons as well as extrapolations across exposure conditions. Although the BBDR models do not necessarily redefine the current practice of risk assessment using either the NOAEL or the benchmark approach, information derived from these efforts should provide a credible scientific basis for the estimates of RfD.

Perforated appendicitis is not a contraindication to laparoscopy

Recent studies have reported an increased risk of intra-abdominal abscess formation following laparoscopic operation for perforated appendicitis. We undertook this study to compare laparoscopic versus open appendectomy in the treatment of perforated appendicitis. Records of all patients undergoing an appendectomy between January 1994 and June 1997 were reviewed, classifying appendicitis as acute, gangrenous, or perforated based on the intraoperative findings. Operative procedures were categorized as open, laparoscopic converted to open, or laparoscopic. The study group included 690 patients; four hundred fourteen (60%) were acute, 77 (11%) were gangrenous, and 199 (29%) were perforated. Although mean length of stay was shorter for all patients undergoing laparoscopic appendectomy, patients with perforated appendicitis had similar length of stay between treatment groups. Mean operative time for open appendectomy was significantly shorter than for converted or laparoscopic appendectomy regardless of diagnosis (P<0.01). Ten patients (1.4%) developed an intra-abdominal abscess: six after open appendectomy (1.7%), one after converted appendectomy (3.7%), and three after laparoscopic appendectomy (1%). There was no significant difference in rate of abscess formation in patients with perforated appendicitis undergoing open, converted, or laparoscopic appendectomy. We conclude that laparoscopic appendectomy for perforated appendicitis is not associated with an increased rate of intra-abdominal abscess formation.

Feeding strategies for premature infants: beneficial outcomes of feeding fortified human milk versus preterm formula

BACKGROUND

In a large-scale study of feeding strategies in premature infants (early vs later initiation of enteral feeding, continuous vs bolus tube-feeding, and human milk vs formula), the feeding of human milk had more effect on the outcomes measured than any other strategy studied. Therefore, this report describes the growth, nutritional status, feeding tolerance, and health of participating premature infants who were fed fortified human milk (FHM) in comparison with those who were fed exclusively preterm formula (PF).

METHODS

Premature infants were assigned randomly in a balanced two-way design to early (gastrointestinal priming for 10 days) versus late initiation of feeding (total parenteral nutrition only) and continuous infusion versus intermittent bolus tube-feeding groups. The type of milk was determined by parental choice and infants to receive their mother's milk were randomized separately from those to receive formula. The duration of the study spanned the entire hospitalization of the infant. To evaluate human milk versus formula feeding, we compared outcomes of infants fed >50 mL. kg-1. day-1 of any human milk (averaged throughout the hospitalization) with those of infants fed exclusively PF. Growth, feeding tolerance, and health status were measured daily. Serum indices of nutritional status were measured serially, and 72-hour nutrient balance studies were conducted at 6 and 9 weeks postnatally.

RESULTS

A total of 108 infants were fed either >50 mL. kg-1. day-1 human milk (FHM, n = 62) or exclusively PF (n = 46). Gestational age (28 +/- 1 weeks each), birth weight (1.07 +/- 0.17 vs 1.04 +/- 0.19 kg), birth length and head circumference, and distribution among feeding strategies were similar between groups. Infants fed FHM were discharged earlier (73 +/- 19 vs 88 +/- 47 days) despite significantly slower rates of weight gain (22 +/- 7 vs 26 +/- 6 g. kg-1. day-1), length increment (0.8 +/- 0.3 vs 1.0 +/- 0.3 cm. week-1), and increment in the sum of five skinfold measurements (0.86 +/- 0.40 vs 1.23 +/- 0.42 mm. week-1) than infants fed PF. The incidence of necrotizing enterocolitis and late-onset sepsis was less in the FHM group. Overall, there were no differences in any measure of feeding tolerance between groups. Milk intakes of infants fed FHM were significantly greater than those fed PF (180 +/- 13 vs 157 +/- 10 mL. kg-1. day-1). The intakes of nitrogen and copper were higher and magnesium and zinc were lower in group FHM versus PF. Fat and energy absorption were lower and phosphorus, zinc, and copper absorption were higher in group FHM versus PF. The postnatal retention (balance) surpassed the intrauterine accretion rate of nitrogen, phosphorus, magnesium, zinc, and copper in the FHM group, and of nitrogen, magnesium, and copper in the PF group.

CONCLUSIONS

Although the study does not allow a comparison of FHM with unfortified human milk, the data suggest that the unique properties of human milk promote an improved host defense and gastrointestinal function compared with the feeding of formula. The benefits of improved health (less sepsis and necrotizing enterocolitis) associated with the feeding of FHM outweighed the slower rate of growth observed, suggesting that the feeding of FHM should be promoted actively in premature infants.

The use of human milk and breastfeeding in premature infants

Human milk is beneficial in the management of premature infants. The beneficial effects generally relate to improvements in host defenses, digestion, and absorption of nutrients, gastrointestinal function, neurodevelopment, and maternal psychological well-being. The use of fortified human milk generally provides the premature infant adequate growth, nutrient retention, and biochemical indices of nutritional status when fed at approximately 180 mL/kg/day compared with unfortified human milk. Human milk can only support the needs of the premature infant if adequate milk volumes are produced. Intensive efforts at lactation support are desirable. Therefore, neonatal centers should encourage the feeding of fortified human milk for premature infants along with skin-to-skin contact as a reasonable method to enhance milk production and promote success with early breastfeeding, while potentially facilitating the development of an enteromammary response.

Identification of a large region of secondary structure in the 3'-untranslated region of chicken elastin mRNA with implications for the regulation of mRNA stability

Synthesis of aortic elastin peaks in the perinatal period and then is strongly down-regulated with postnatal vascular development. Our laboratory has previously shown that changes in elastin mRNA stability contribute to this developmental decrease in elastin production. Here we identify a large region of stable secondary structure in the 3'-untranslated region (3'-UTR) of chicken elastin mRNA. Reverse transcriptase polymerase chain reaction or polymerase chain reaction amplification of the 3'-UTR consistently resulted in products with an approximately 328-bp deletion from the central region of the 3'-UTR, suggesting the presence of secondary structure. The presence of this structure was confirmed by probing the 3'-UTR with RNases with selectivity for single- or double-stranded RNA. Gel migration shift assays using cytosolic extracts from 2-day old chicken aorta demonstrate specific binding of a cytosolic protein to riboprobes containing the 3'-UTR of elastin but not to riboprobes either corresponding to other areas of the message or containing the 3'-UTR but lacking the region of secondary structure. Binding of cytosolic protein was particularly prominent in aortic extracts from 2-day old chickens, a time when elastin message is stable, as compared with 8- and 15-week old chickens, when the elastin message is relatively unstable, suggesting that this region of secondary structure may play a role in developmental regulation of stability of elastin mRNA.

Feeding strategies for premature infants: randomized trial of gastrointestinal priming and tube-feeding method

BACKGROUND

Data on enteral feeding management of premature infants are limited and often not the subject of randomized clinical trials. Several small studies suggest benefits from the early initiation of feeding, but do not assess the combined effects of time of initiation of feeding, tube-feeding method, and type of milk used. Either singly or in combination, these treatments may affect growth, bone mineralization, biochemical measures of nutritional status, and feeding tolerance, and, ultimately, the duration of hospitalization.

METHODS

A total of 171 premature infants, stratified by gestational age (26 to 30 weeks) and diet (human milk or preterm formula) were assigned randomly among four treatment combinations in a balanced two-way design comparing the presence or absence of gastrointestinal (GI) priming for 10 days and continuous infusion versus intermittent bolus tube-feeding.

RESULTS

The major outcome, time required for infants to attain full oral feeding, was similar among treatments. GI priming was not associated with any measured adverse effect and was associated with better calcium and phosphorus retention, higher serum calcium and alkaline phosphatase activity, and shorter intestinal transit times. The bolus tube-feeding method was associated with significantly less feeding intolerance and greater rate of weight gain than the continuous method. In addition, the greater the quantity of human milk fed, the lower the morbidity.

CONCLUSIONS

Early GI priming with human milk, using the bolus tube-feeding method, may provide the best advantage for the premature infant.

Quality ratings of a hospital foodservice department by inpatients and postdischarge patients

OBJECTIVES

To examine quality of food and nutrition services using the ratings of inpatients and patients who had been discharged (postdischarge patients).

DESIGN

Questionnaires were used to collect perceptions of inpatients and postdischarge patients on the quality of food and nutrition services. A 5-point scale allowed subjects to rate quality from very poor to very good.

SUBJECTS

Questionnaires were completed by 252 inpatients and 437 postdischarge patients of a midwestern teaching hospital.

STATISTICAL ANALYSIS

Analysis of variance was used to assess differences in quality ratings on the basis of demographic variables. Stepwise regression was used to determine variables that best predicted overall satisfaction. Paired t tests were conducted to compare matched inpatient and postdischarge ratings.

RESULTS

Ratings of food and nutrition services indicated that patients were satisfied; few differences were found in ratings on the basis of patient demographics. Food quality was the best predictor of overall satisfaction for both inpatients and postdischarge patients. As patient expectations were increasingly met or exceeded, patient ratings of quality increased. The majority of patients in the matched sample gave the same ratings on the inpatient and postdischarge questionnaires.

APPLICATIONS

Foodservice managers who desire to improve patient satisfaction should focus attention on meeting or exceeding patient expectations for food quality.

Early feeding, feeding tolerance, and lactase activity in preterm infants

OBJECTIVE

We sought to ascertain whether the timing of feeding initiation affected the development of intestinal lactase activity and whether there are clinical ramifications of lower lactase activity.

STUDY DESIGN

Preterm infants (26 to 30 weeks' gestation; n = 135) were randomly assigned to begin enteral feedings at either 4 (early group) or 15 days of age (standard group). At 10, 28, and 50 days of age lactase activity was determined by measuring the urinary ratio of lactulose/lactose after the 2 sugars were administered.

RESULTS

Lactase activity increased significantly over time. Infants in the early group had greater lactase activity at 10 days of age (by 100%) and 28 days of age (by 60%) than the standard group. At 10 days of age lactase activity was greater in milk- versus formula-fed infants. The time required to achieve full enteral feedings, the number of abnormal abdominal x-ray examinations, and the total number of abdominal x-ray examinations were inversely related to lactase activity.

CONCLUSIONS

Early feeding increases intestinal lactase activity in preterm infants. Lactase activity is a marker of intestinal maturity and may influence clinical outcomes. Whether the effects of milk on lactase activity were due to the greater concentration of lactose in human milk compared with that in formula must be determined.

Development of cholinergic neurons in rat brain regions: dose-dependent effects of propylthiouracil-induced hypothyroidism

The effects of hypothyroidism on development of cholinergic system in brain regions (prefrontal cortex and hippocampus) were evaluated by measuring choline acetyltransferase (ChAT) activity and hemicholinium-3 binding to the high-affinity choline transporter. Various degrees of thyroid deficiency were produced by perinatal exposure to propylthiouracil (PTU) in drinking water ranging from 5 ppm (mg/l) to 25 ppm beginning at gestational day 18 until postnatal day 21. ChAT, a marker for cholinergic nerve terminals, was reduced by PTU in a dose-dependent manner. Concomitant with the enzyme deficits, hemicholinium-3 binding was elevated, suggesting an increase in neuronal impulse activity. Although similar changes were seen in both brain regions examined, the magnitude and duration of these changes were more definitive in the prefrontal cortex. Nonetheless, these neurochemical alterations appeared to be recoverable when the rats returned to a euthyroid state, and no further changes were observed as the animals reached adulthood. In comparison, data reported in a succeeding article indicate that deficits in cognitive function were first seen in weanling hypothyroid rats, but that the behavioral impairments lasted well into adulthood when thyroid status and cholinergic parameters in the brain appeared to have recovered to normal. These results suggest that alterations of cholinergic system caused by perinatal hypothyroidism are associated with neurobehavioral deficits at weaning, and these developmental deviations may cause permanent impairment of cognitive function despite recovery from the hormonal imbalance at adult ages.

Early feeding, antenatal glucocorticoids, and human milk decrease intestinal permeability in preterm infants

To determine the effects of age, feeding regimen, and antenatal glucocorticoids on intestinal permeability, preterm infants (n = 132) were stratified by gestational age and by diet (mothers' own milk versus preterm formula), and assigned randomly to one of four feeding regimens: early-continuous, early-bolus, standard-continuous, and standard-bolus. At 10, 28, and 50 d of age permeability was determined by measuring the ratio of lactulose/ mannitol in the urine after the two sugars were administered enterally for 30 h. The mean (+/-SE) birth weight and gestational age of the infants were 1044 +/- 13 g and 27 +/- 0.1 wk, respectively. Permeability changed as a function of age (p = 0.003). Early feeding was associated with a reduction in permeability at 10 d of age (p = 0.01). Antenatal steroid administration was associated with decreased permeability at 28 d of age (p = 0.017). The feeding of human milk (versus formula) was associated with decreased permeability at 28 d of age (p = 0.02). Continuous versus bolus feeding did not affect permeability.

The development of sinoatrial dysfunction in pacemaker patients with isolated atrioventricular block

The purpose of this paper is the assessment of sinus node competence over time in patients with isolated atrioventricular block (AV block). Patients implanted with AV synchronous pacemakers for isolated AV block between December 1993 and June 1995 were prospectively evaluated at predischarge, 6 weeks, and subsequent 6 months follow-up with respect to atrial rate monitors/24-hour Holter and modified exercise test. Patients unable to maintain AV synchronous pacing or complete a modified exercise test were excluded. Sinus node competency is interpreted as: (1) absence of atrial brady- or tachyarrhythmia, (2) ability to achieve a minimum heart rate of 100 beats/min with modified exercise test or during daily activities. There were 58 patients (22 women), mean age 71.0 +/- 13.8 with an average follow-up of 30.4 months (11-40). Three patients did not complete a modified exercise test, 4 patients were lost to follow-up, and 2 patients were unable to maintain AV synchronous pacing. Of the remaining 49 patients, 3 developed chronic or paroxysmal atrial fibrillation. No patient developed significant bradyarrhythmias. All patients achieved a heart rate of > or = 100 beats/min modified exercise test. In our group of patients with isolated AV block within a moderate follow-up period, development of sinoatrial dysfunction was rare (6%). A longer follow-up is required to delineate the natural history of sinoatrial dysfunction in patients with isolated AV block.

Sample preparation and high-performance liquid chromatographic analysis of deoxyribonucleoside triphosphates in individual rat embryos

A rapid, robust, and sensitive method has been developed to measure concentrations of deoxyribonucleoside triphosphates in individual, day 14 rat embryos by modifying and optimizing existing methods for cellular extracts. Significant changes include: (i) oxidative degradation of ribonucleoside triphosphates using methylamine at lower pH (decreased from 6.5 to 4.0) to improve poor HPLC peak shape of early eluting nucleotides; (ii) glass fiber disc solid-phase extraction of the reaction mixture, which dramatically reduces impurities that interfere with nucleotide measurement, eliminates the necessity of column regeneration, and allows mobile phase recycling; and (iii) lower ionic strength (reduced from 0.4 to 0.26 or 0.12 M ammonium phosphate) and higher pH (increased from 3.25 to 5.55 or 6.98, respectively) mobile phase, conditions which are less destructive to the column's bonded phase and silica support, thereby contributing to longer column life. Enhancements include: (i) filtration of the sample prior to HPLC injection and addition of an in-line filter, guard column, and saturating precolumn of silica in the mobile phase flow, which aids substantially in extending column life and improves chromatographic stability, and (ii) inclusion of an internal standard to correct for mechanical losses. Limits of determination at a signal to noise ratio of 6:1 range from 5.5 to 12 pmol on-column or 0.41 to 0.87 pmol/mg of embryonic tissue depending on the specific nucleotide. Recoveries are quantitative for all nucleotides, and interassay variabilities are between 5 and 7% when quantified by peak height. The method has also been applied successfully to analysis of murine erythroleukemic cell cultures and this, when coupled with the embryo results, suggests its general utility.

Comparison study of QuickCast versus a traditional thermoplastic in the fabrication of a resting hand splint

Therapists are frequently presented with new splinting material promising better and faster results. Managed care and cost containment make it important to evaluate the splinting materials used in the fabrication process. A new precut splint, QuickCast, is made from a fiberglass material that becomes pliable from the heat of a standard household hair dryer. Graduate occupational therapy students participated in timed trials fabricating resting hand splints with QuickCast and Ezeform brands of thermoplastic. Second-year occupational therapy students chosen as splint makers answered a questionnaire measuring fit, edges, strap application, aesthetics, safety, and ease of positioning. First-year students who had no neurologic or orthopedic involvement in the upper extremities participated as clients. They answered a questionnaire on comfort, weight, and aesthetics of the splint and the safety and comfort of the splinting process. Analysis of timed trials revealed no significant difference in the time required to fabricate the QuickCast precut thermoplastic and the sheet thermoplastic splints. From the questionnaire, the thermoplastic splint was rated safer than the QuickCast material by splint makers. Further studies are suggested for comparing time and cost effectiveness between commercially available splinting materials.

Non-invasive image acquisition and advanced processing in optical bioimaging

Light is a most versatile tool for investigating biological systems and phenomena; the range, non-destructiveness, spatial discrimination and speed of optical imaging are all important for investigating structure and function at the cellular, tissue or even whole organism level. In live biological imaging, where the technological requirements are heightened, other features of light, such as coherence and wavelength, are used to generate the additional contrast and resolution needed. We report here recent improvements in our ability to image biological specimens optically, focusing on (a) spectral resolution and the related image processing issues, and (b) tomographic three-dimensional fluorescence imaging in vivo.

When pacemakers fail: an analysis of clinical presentation and risk in 120 patients with failed devices

Although pacemaker recalls are common, the optimal mechanism for risk assessment and triage of patients at risk for sudden loss of device system function is unknown. A retrospective chart review of 120 patients with factory proven failed devices was performed. Logistic regression analysis was used to determine clinical correlates of emergency room versus outpatient clinic presentation at time of device failure. Twenty-two patients (18%) presented to emergency and 98 (82%) to clinic. Sixty-three devices had no device output at the time of presentation. Multivariate logistic regression analysis revealed that antiarrhythmic drug use (odds ratio: 7.4, 95% CI: 2.0-28.0), atrioventricular nodal disease as an indication for pacing (odds ratio: 2.8, 95% CI: 1.2-3.0), and female gender (odds ratio: 2.2, 95% CI: 1.0-4.5) were the only significant correlates of emergency room presentations. Pacemaker dependency (escape heart rate < 40 beats/min) did not correlate with location of presentation even though no device output at the time of presentation was associated with emergency room presentation (odds ratio: 2.5, 95% CI: 1.1-5.8). Neither the presence of structural heart disease nor symptoms at the time of device implantation (syncope or presyncope) were correlated with location of presentation upon unexpected device failure. Although there were no deaths in the 120 failed devices studied, there were 26 deaths in the total group of 227 patients with recalled devices that could not be studied. Antiarrhythmic drug use, electrocardiographic pacing indication, and female gender may be more sensitive predictors of emergency room presentation and significant symptoms in the event of unanticipated pacemaker failure. The inability of any retrospective analysis to accurately assess mortality in the setting of pacemaker system failure underscores the need for prospective databases in recall situations.

Nucleoside-mediated mitigation of 5-fluorouracil-induced toxicity in synchronized murine erythroleukemic cells

5-Fluorouracil (5-FU) is a chemotherapeutic agent known to retard embryonic growth and induce cleft palate and limb deformities. The predominant mechanism underlying its toxic action is thought to be inhibition of thymidylate synthetase (TS), and hence thymidine triphosphate (dTTP) synthesis, resulting in alteration of the balance of deoxynucleotide (dNTP) pools and disruption of DNA synthesis. Indeed, previously we demonstrated retarded cell-cycle progression concurrent with a 60% decrease in TS activity in rat whole embryos following maternal exposure to 40 mg/kg 5-FU on Gestational Day 14 and in the murine erythroleukemic cell (MELC) suspension culture following exposure to 5-25 microM 5-FU for 2 hr. In the study described herein, we used high-performance liquid chromatography (HPLC) to demonstrate in both of these model systems that 5-FU exposure results in similar patterns of dNTP perturbations: a prolonged decrease in dTTP and dGTP levels and an increase in dCTP and dATP. In addition, we used centrifugal elutriation to synchronize MELC in the phases of the cell cycle (G0/G1 and early S) most sensitive to 5-FU to investigate the ability of nucleoside supplementation to mitigate 5-FU-induced toxicity. Our data indicate that following a 2-hr exposure to 5-25 microM 5-FU, supplementation with 1-10 microM thymidine (TdR) for 24 hr partially reverses 5-FU-induced toxicity as evidenced by increased cellular proliferation and cell-cycle progression and amelioration of 5-FU-induced perturbations of protein synthesis and cellular membrane permeability compared to unsupplemented 5-FU-exposed cells. However, TdR concentrations >/=100 microM inhibited growth or were cytotoxic. In comparison, supplementation with 10 microM-10 mM of deoxycytidine (CdR) was not toxic, but effected a dose-dependent recovery from 5-FU-induced toxicity. At 1-100 microM, neither deoxyadenosine nor deoxyguanosine supplementation reduced 5-FU-induced toxicity; at higher concentrations, both purine nucleotides inhibited cell growth. Although these results support the hypothesis that 5-FU disrupts the MELC cell cycle by depleting dTTP (a perturbation that is reversible by TdR supplementation), they also indicate that CdR supplementation offers an additional recovery pathway.

Is this the natural history of the retention wire? A case report

We report on a 71-year-old man who had a dual chamber pacemaker implanted in 1991. A Class IV fracture of the Telectronics Accufix 330-801 atrial lead was observed on a chest X ray in December 1993. Serial chest X ray and fluoroscopy documented stable position of the migrated fractured J wire. The patient remained asymptomatic and a decision for conservative monitoring was made. A subsequent finding of a right atrial mass on echocardiography and evidence of pulmonary embolism on lung scan prompted a change of strategy. The patient underwent atriotomy, and a right atrial thrombus was discovered associated with the fractured J retention wire, both of which were extracted uneventfully. This case is illustrative that despite apparent stability of a Class IV fracture, it may result in endothelial injury with a thrombogenic nidus and resultant complications.

Oral feeding in low birth weight infants

To gain a better understanding of the development of sucking behavior in low birth weight infants, the aims of this study were as follows: (1) to assess these infants' oral feeding performance when milk delivery was unrestricted, as routinely administered in nurseries, versus restricted when milk flow occurred only when the infant was sucking; (2) to determine whether the term sucking pattern of suction/ expression was necessary for feeding success; and (3) to identify clinical indicators of successful oral feeding. Infants (26 to 29 weeks of gestation) were evaluated at their first oral feeding and on achieving independent oral feeding. Bottle nipples were adapted to monitor suction and expression. To assess performance during a feeding, proficiency (percent volume transferred during the first 5 minutes of a feeding/total volume ordered), efficiency (volume transferred per unit time), and overall transfer (percent volume transferred) were calculated. Restricted milk flow enhanced all three parameters. Successful oral feeding did not require the term sucking pattern. Infants who demonstrated both a proficiency > or = 30% and efficiency > or = 1.5 ml/min at their first oral feeding were successful with that feeding and attained independent oral feeding at a significantly earlier postmenstrual age than their counterparts with lower proficiency, efficiency, or both. Thus a restricted milk flow facilitates oral feeding in infants younger than 30 weeks of gestation, the term sucking pattern is not necessary for successful oral feeding, and proficiency and efficiency together may be used as reliable indicators of early attainment of independent oral feeding in low birth weight infants.

Levels of selected organic compounds in materials for candle production and human exposure to candle emissions

Polychlorinated dibenzo-p-dioxins (PCDD), dibenzofurans (PCDF) selected chlorinated pesticides, polycyclic aromatic hydrocarbons (PAH) and some volatile organic compounds (VOC) were analysed in the exhaust fumes of candles made from different waxes and finishing materials. To guarantee defined burning conditions a chamber was developed for the sampling of the exhaust fumes. Using a simple exposure model, the inhalative uptake of PCDD/PCDF by an adult person was calculated for different scenarios. It was shown that additional uptake of PCDD/PCDF caused by candle emissions does not contribute significantly to the total daily intake of these compounds. Emissions of PCDD/PCDF, benzo(a)pyrene and the VOC were then compared to limit value for working places. Even when many candles would be burnt at the same time in a small room, concentrations of the compounds investigated stay below 1% of the tolerable limit values.

Comparison of preferred frequency gain settings obtained with category rating and modified simplex procedure

We examined the relations between the preferred frequency gain settings obtained from the modified simplex procedure and those that were rated highest during category rating at three speech and noise levels (speech and noise levels at 60/65, 63/63, 65/60, all in dBA). During category rating, subjects rated short discourse passages on a 7-point scale using clarity and noise interference as criteria. Clarity was used as criterion in the modified simplex procedure. Results indicated that most subjects gave the same high rating to two or more frequency gain settings during category rating. Such settings varied across subjects and test conditions. The preferred frequency gain settings selected with the modified simplex procedure matched closely those rated highest in clarify and lowest in noise interference. This suggests that the modified simplex procedure may be used to determine preferred frequency gain setting on a hearing aid.

Gene transfer into fetal rat intestine

To assess the fetal intestine as a site for gene therapy, we have explored a xenograft model in which fetal rat intestine is grafted subcutaneously into nu/nu mice. Prior to grafting, the tissue was exposed to a replication-deficient retroviral vector bearing the neo gene. Transduction efficiency was assessed by quantitative polymerase chain reaction (PCR) of neo in DNA recovered from the grafts. Three methods of infection were employed: (i) simple flushing of the fetal intestine with the vector; (ii) incubation with the vector for 2 hr; and (iii) a combination of both. The first method gave the highest transduction efficiencies in terms of both the proportion of samples that were neo-positive and the number of neo-positive cells per sample. Using this approach, the time course of persistence of neo-positive cells was analyzed by collecting grafts at 1 versus 3 weeks post-infection. The results showed approximately five-fold more positive cells at the earlier time point than at the later, suggesting loss of transduced cells due to cell turnover. Nevertheless, the persistence of a portion of the positive cells for at least 3 weeks is encouraging for future studies with fetal intestine.

Cardiac pacing following surgery for acquired heart disease

BACKGROUND

This study is comprised of 3493 consecutive patients who underwent open heart surgery at our institution. Data on all patients were collected prospectively.

METHODS

In 45 patients (Group P) (1.3%), a permanent pacemaker (PP) was inserted postoperatively. For the purpose of the study, these patients were compared to 3448 patients (Group NP) who did not require insertion of a PP after surgery. Mean follow-up was 33 months (range 1.5 to 66).

RESULTS

We found Group P patients were older (64.8 +/- 11.0 vs 61.0 +/- 11.0 years, p < 0.05), had a higher proportion of elderly (> 70 years) 36% vs 19%, p = 0.01), and of female patients (48.8% vs 22.7%, p < 0.001) compared to Group NP. Group P also had a higher incidence of preoperative rhythm abnormalities (26.6% vs 5.7%, p < 0.0001), redo surgery (13.3% vs 4.6%, p = 0.02), aortic valve surgery (48.8% vs 10.8%, p < 0.001), and tricuspid valve surgery (repair 3, replacement 1) (8.8% vs 0.5%, p < 0.001), in addition to a higher proportion of patients in whom cold (vs warm) blood cardioplegia was used (68.8% vs 52.3%, p = 0.03). Indication for postoperative PP was sick sinus syndrome (SSS) in nine patients; atrial fibrillation in eight patients; atrioventricular block (AVB) in 27 patients; and combined AVB/SSS in 1 patient. There were no operative deaths in Group P. Necessity for PP after heart surgery had a significant impact on resource utilization resulting in prolonged ventilation (3.1 +/- 7.5 vs 1.4 +/- 3.3 days, p < 0.01), intensive care unit (5.1 +/- 10.2 vs 2.5 +/- 4.0 days, p < 0.01), and postoperative hospital stay (18.0 +/- 13.4 vs 8.1 +/- 9.4 days, p < 0.01).

CONCLUSIONS

By multivariate logistic regression (odds ratio and p value in parentheses), aortic valve surgery (8.23, p = 0.001), the absence of preoperative sinus rhythm (5.60, p = 0.001), postoperative myocardial infarction (3.46, p = 0.024), and female gender (2.52, p = 0.003), were found to be independent predictors for PP requirement post surgery.