Introduction of hospital quality measures may lead to a temporary decrease in patient outcomes

OBJECTIVES

To analyse the impact of hospital quality indicators on hip fracture mortality in Israel.

STUDY DESIGN

A retrospective observational study.

METHODS

Data were collected on all patients aged ≥65 years with an isolated hip fracture in the years 2010-2016 from the Israel's National Trauma Registry. These data were then cross checked with information on co-morbidities and medication intake from the Clalit medical fund. All successfully matched patients constituted the study population. The main outcome measures were in-hospital and 1-year mortality. Trend analysis of surgery on hip fractures within 48 h of hospitalisation (referred to as early hip fracture surgeries) and mortality was performed. The introduction of the proportion of early hip fracture surgeries as an official quality parameter in 2013 was considered an intervention.

RESULTS

The proportion of early hip fracture surgeries continuously increased during the study period and, after the introduction of the quality measure, a significant increase in the uniformity of practice among hospitals was observed. The mortality trend was not related to the early surgeries trend, with a sharp upward spike detected in 2014, followed by a gradual return to previous levels in the subsequent years. The analysis has shown that when adjusting for demographic factors and co-morbidity, both in 2010-2013 and in 2015-2016, a clear benefit in survival existed for patients who were operated on within the first 48 h. In 2014, which was the first year of open publication of achieved quality measures reported in the media, no such benefit was found.

CONCLUSIONS

Even when an improvement in a promoted practice is achieved, its positive impact on clinical outcomes may be delayed, possibly indicating the need for a learning period.

Achieving Histologic Normalization in Ulcerative Colitis Is Associated With a Reduced Risk of Subsequent Dysplasia

BACKGROUND

Complete histologic normalization is associated with improved clinical outcomes in ulcerative colitis (UC). However, it is currently unknown what effect achieving histologic normalization has on the development of dysplasia.

METHODS

We performed a retrospective analysis of 495 patients with a confirmed diagnosis of UC from a tertiary center. Patients were categorized according to the best histologic assessment they had during their disease course: histologic normalization, histologic quiescence, or persistent histologic activity. We assessed dysplasia rates in these patient groups after achieving histologic normalization or histologic quiescence, or 8 years after UC diagnosis in those with persistent histologic activity. Kaplan-Meier graphs and Cox regression analyses were performed to estimate this effect.

RESULTS

The incidence rate of dysplasia development after achieving histologic normalization was statistically significantly less when compared with the incidence rate after achieving histologic quiescence (P = 0.001) and in those with persistent histologic activity 8 years after UC diagnosis (P = 0.033). In multivariate analysis, at any point throughout UC duration, dysplasia development was statistically lower in those with histologic normalization (adjusted hazard ratio [aHR], 0.32; 95% confidence interval [CI], 0.13-0.81) but not in those with histologic quiescence (aHR, 0.52; 95% CI, 0.25-1.10), compared with those with persistent histologic inflammation. When assessing the time after achieving histologic normalization, histologic quiescence, or 8 years post UC diagnosis in those with persistent histologic activity, we found that patients with histologic normalization had a subsequent decreased risk of developing dysplasia (aHR, 0.09; 95% CI, 0.01-0.72), compared with patients without normalization.

CONCLUSIONS

Histologic normalization is associated with a decreased risk in patients with UC of developing subsequent dysplasia, compared with patients without histologic normalization. These findings have implications for surveillance intervals.

Follow-Up of Patients With Ulcerative Colitis and Histological Normalization

The natural history of ulcerative colitis (UC) follows a relapsing and remitting course of inflammation and is accompanied by associated mucosal injury and historically, microscopic features of chronicity that were the sine qua non for the diagnosis.¹ As goals for the management of UC have evolved to include objectively measured endoscopic improvement of the mucosa, there also has been a move to include histological endpoints in assessment of disease activity.^2,3 However, there remain a number of unanswered questions about histology in UC and this is not yet a specific treatment goal.⁴.

Efficacy and safety of induction therapy with calcineurin inhibitors followed by vedolizumab maintenance in 71 patients with severe steroid-refractory ulcerative colitis

BACKGROUND

Following induction therapy with a calcineurin inhibitor (CNI) in severe ulcerative colitis, transitioning to vedolizumab as maintenance therapy could be an option.

AIM

To report on the largest cohort of patients successfully induced with CNIs who were transitioned to vedolizumab maintenance therapy.

METHODS

This is a retrospective observational study of adult patients with severe steroid-refractory ulcerative colitis. Patients were included if they were induced with a CNI followed by maintenance therapy with vedolizumab between January 2014 and December 2018. The primary endpoint was colectomy-free survival. Secondary endpoints included survival without vedolizumab discontinuation as well as clinical, steroid-free and biochemical remission at week 14.

RESULTS

A total of 71 patients (59% male) were treated with vedolizumab after induction therapy with CNIs for severe steroid-refractory colitis. Patients were followed for a median time of 25 months (IQR 16-36). Colectomy-free survival rates from vedolizumab initiation were 93% at 3 months, 67% at 1 year and 55% at 2 years. At the end of induction with vedolizumab at week 14, 50% of patients were in clinical remission, and 62% of patients had a normal CRP. At 1 and 2 years following vedolizumab initiation, 43% and 28% of patients were still on vedolizumab respectively. Vedolizumab was dose escalated to infusions every 4 weeks in 44% of patients. The median time to dose escalation was 5.6 months (IQR 4.1-8.2). No serious adverse events were recorded in our patient cohort.

CONCLUSIONS

Transitioning to vedolizumab following induction of remission with CNIs is effective and safe.

Outcome of elective switching to vedolizumab in inflammatory bowel disease patients under tumor necrosis factor antagonist-maintained clinical remission

BACKGROUND AND AIM

Vedolizumab (VDZ) has been used in inflammatory bowel disease (IBD) patients who failed anti-tumor necrosis factor (TNF) therapy. This study was to examine long-term outcome of IBD patients switching to VDZ from anti-TNF agents for reasons other than failure of therapy.

METHODS

Inflammatory bowel disease patients at the University of Chicago IBD center who were in clinical remission with anti-TNF therapy and then electively changed to VDZ due to reasons other than loss of response were retrospectively analyzed. The primary outcome was the durability of clinical remission maintained by VDZ as assessed by Kaplan-Meier survival analysis. The proportion of patients in clinical and endoscopic remission at 6-12 months after switching to VDZ therapy was analyzed.

RESULTS

A total of 41 patients (36 with Crohn's disease and 5 with ulcerative colitis) met the inclusion criteria and were in clinical remission at the time of switch. The majority of patients switched therapy due to adverse effects (56.1%) or infections (14.6%). During a median duration of 30 months (range 7-52) of VDZ therapy, 34 (82.9%) were in VDZ-maintained clinical remission. One (2.4%) and four (9.8%) patients discontinued VDZ due to flare and adverse effects, respectively. Endoscopic remission was present in 25 of 30 patients (83.3%) who had a follow-up colonoscopy.

CONCLUSIONS

Vedolizumab was effective and safe in maintaining remission in IBD patients who switched from anti-TNF agents due to reasons other than failure of therapy. Our results suggest that switching anti-TNF remitters to VDZ treatment is a safe practice in specific patient populations.

Proposal to Update the Curriculum in Inflammatory Bowel Diseases for Categorical Gastroenterology Fellows

Education in inflammatory bowel disease (IBD) varies widely between categorical gastroenterology (GI) programs and is largely related to the presence of expert clinicians, patient population, and the presence of an IBD center. The treatment of IBD is becoming increasingly complex at a rapid pace, widening this educational divide. This manuscript outlines all the current US educational offerings in IBD for GI fellows, including how to obtain supplemental education during the 3-year training period and beyond. It reviews how to assess trainee knowledge in the field of IBD and proposes 8 clinically anchored, entrustable professional activities that should help prioritize important aspects of IBD management to incorporate during categorical GI training.

Differential risk of disease progression between isolated anastomotic ulcers and mild ileal recurrence after ileocolonic resection in patients with Crohn's disease

BACKGROUND AND AIMS

It is standard of care to perform ileocolonoscopy within a year of ileocolonic resection for Crohn's disease (CD) and to guide management decisions based on the Rutgeert score (RS). The modified RS subdivides i2 into lesions confined to the anastomosis (i2a) or >5 aphthous lesions in the neoterminal ileum (i2b). There is uncertainty, however, if i2a lesions incur an increased risk of disease recurrence. The primary aim of this study was to compare the rates of endoscopic progression between i2a and i2b when compared with i0-i1.

METHODS

This was a retrospective, single-center study including patients with CD who had an ileocolonoscopy ≤12 months after ileocolonic resection with primary anastomosis and who had >1 year of documented clinical follow-up after the index endoscopic evaluation. All consecutive eligible patients between 2004 and 2014 were included in the study. Demographic, disease, and treatment data were collected. Patients with i3 or i4 at index colonoscopy were excluded from further analyses. Outcomes included endoscopic progression and recurrent surgery. For patients with RS of i0 to i2, endoscopic progression was predefined as progression of the RS in subsequent colonoscopies to i3 or i4. Recurrent surgical interventions were defined as re-resection or stricturoplasty of the previous ileocolonic anastomosis.

RESULTS

Two hundred seven CD patients (median age, 36 years [interquartile range, 26-48]) had an ileocolonoscopy ≤12 months after ileocolonic resection. At index colonoscopy, 95 patients (45.9%) had an RS of i0, 31 (14.9%) i1, 40 (19.3%) i2a, 25 (12.1%) i2b, 10 (4.8%) i3, and 6 (2.9%) i4. One hundred ninety-one patients had an RS of i0 to i2 and were included in the analyses for recurrent surgery. One hundred forty-nine patients had a second endoscopic evaluation and were included in the analysis for the primary outcome of endoscopic disease progression. Kaplan-Meier analyses were performed and found the hazard ratio (HR) of endoscopic progression to be significantly higher with i2b lesions when compared with i0 or i1 (HR, 6.22; 95% confidence interval [CI], 2.38-16.2; P = .0008). Patients with i2a did not have significantly higher rates of endoscopic progression when compared with i0 or i1 (HR, 2.30; 95% CI, .80-6.66; P = .12). Likewise, patients with i2b lesions had higher risk of needing recurrent surgery when compared with i0 or i1 (HR, 3.64; 95% CI, 1.10-12.1; P = .034), whereas patients with i2a lesions were not found to have a significantly elevated risk of recurrent surgery (HR, 1.43; 95% CI, .35-5.77; P = .62).

CONCLUSION

Endoscopic lesions limited to the ileocolonic anastomosis (RS i2a) in patients with CD undergoing colonoscopy within 1 year of their resection were not associated with a significantly higher rate of progression to more severe disease, whereas those in the neoileum (RS i2b) were. Prospective studies are needed to confirm these findings.

A clinical predictive model for post-hospitalisation venous thromboembolism in patients with inflammatory bowel disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at increased risk of venous thromboembolism (VTE) during hospitalisation and potentially post-discharge.

AIMS

To determine the incidence and risk factors for post-discharge VTE in IBD patients and create a point of care predictive model to assess VTE risk.

METHODS

Hospitalised IBD patients were identified from our institutional discharge database between 2009 and 2016, and were assessed for VTE by chart review. Risk factors for VTE within 3 months of discharge were determined by univariable and multivariable logistic regression. A point of care model was created using variables from the univariate analysis with P < 0.05, and internally validated by bootstrap methods.

RESULTS

Sixty-six of 2161 eligible discharges (3%) were associated with VTE within 6 months of hospitalisation. The median time to event was 37 days (range 3-182 days). On multivariable analysis age >45 years (OR 3.76; 95% CI 1.80-7.89) and multiple admissions (OR 2.62; 95% CI 1.34-5.11) were independently associated with VTE risk. Our final model incorporated age >45 years, multiple admissions, intensive care unit admission, length of admission >7 days and central catheter and was able to discriminate between discharges associated with and without VTE (optimism-corrected c-statistic, 0.70; 95% CI 0.58-0.77). By limiting treatment to a high-risk group, extended thromboprophylaxis could be avoided in 92% of discharges with a miss rate of 1.6% (32/1982 discharges).

CONCLUSION

Patients with IBD remain at risk of VTE after hospital discharge. Our model may help clinicians stratify which patients will benefit most from extended thrombophrophylaxis.

Treatment De-Escalation in Patients With Inflammatory Bowel Disease

Inflammatory bowel disease follows a relapsing and remitting course that can be augmented with the use of various pharmacologic therapies. Treatments used to induce or maintain remission may not be required indefinitely. The associated side-effect profile, adverse events, and costs are additional motivators for providers to treat patients with the lowest dose of effective medications. De-escalation of therapy, whether dose reduction or drug discontinuation, must be carefully considered on an individual patient basis. The steps for de-escalation include confirmation of deep remission, development of a maintenance strategy, discussion of the rescue threshold and treatment options in the event of relapse, and appropriate discussion with the patient of this plan.

Fluid balance, change in serum creatinine and urine output as markers of acute kidney injury post cardiac surgery: an observational study

Background

Acute kidney injury (AKI) is defined as oliguria or rise in serum creatinine but oliguria alone as a diagnostic criterion may over-diagnose AKI.

Objectives

Given the association between fluid overload and AKI, we aimed to determine if positive fluid balance can complement the known parameters in assessing outcomes of AKI.

Design

Prospective observational study.

Setting

Teaching hospital in Vancouver, Canada.

Patients

111 consecutive patients undergoing elective cardiac surgery from January to April 2012.

Measurements

Outcomes of cardiac surgery intensive care unit (CSICU) and hospital length of stay (LOS) in relation to fluid balance, urine output and serum creatinine.

Methods

All fluid input and output was recorded for 72 hours post-operatively. Positive fluid balance was defined as >6.5 cc/kg. Daily serum creatinine and hourly urine output were recorded and patients were defined as having AKI according to the AKIN criteria.

Results

Of the patients who were oliguric, those with fluid overload trended towards longer LOS than those without fluid overload [CSICU LOS: 62 and 39 hours (unadjusted p-value 0.02, adjusted p-value 0.58); hospital LOS: 13 and 9 days (unadjusted p-value: 0.05, adjusted p-value: 0.16)]. Patients with oliguria who were fluid overloaded had similar LOS to patients with overt AKI (change in serum creatinine ≥ 26.5 µmol/L), [CSICU LOS: 62 and 69 hours (adjusted p value: 0.32) and hospital LOS: 13 and 14 days (adjusted p value: 0.19)]. Patients with oliguria regardless of fluid balance had longer CSICU LOS (adjusted p value: 0.001) and patients who were fluid overloaded in the absence of AKI had longer hospital LOS (adjusted p value: 0.02).

Limitations

Single centre, small sample, LOS as outcome.

Conclusions

Oliguria and positive fluid balance is associated with a trend towards longer LOS as compared to oliguria alone. Fluid balance may therefore be a useful marker of AKI, in addition to urine output and serum creatinine.

Electroporation-mediated gene transfer directly to the swine heart

In vivo gene transfer to the ischemic heart via electroporation holds promise as a potential therapeutic approach for the treatment of heart disease. In the current study, we investigated the use of in vivo electroporation for gene transfer using three different penetrating electrodes and one non-penetrating electrode. The hearts of adult male swine were exposed through a sternotomy. Eight electric pulses synchronized to the rising phase of the R wave of the electrocardiogram were administered at varying pulse widths and field strengths following an injection of either a plasmid encoding luciferase or one encoding green fluorescent protein. Four sites on the anterior wall of the left ventricle were treated. Animals were killed 48 h after injection and electroporation and gene expression was determined. Results were compared with sites in the heart that received plasmid injection but no electric pulses or were not treated. Gene expression was higher in all electroporated sites when compared with injection only sites demonstrating the robustness of this approach. Our results provide evidence that in vivo electroporation can be a safe and effective non-viral method for delivering genes to the heart, in vivo.

Effect of nutrient supply on photosynthesis and pigmentation to short-term stress (UV radiation) in Gracilaria conferta (Rhodophyta)

The effects of increased photosynthetic active radiation (PAR), UV radiation (UVR), and nutrient supply on photosynthetic activity, pigment content, C:N ratio and biomass yield were studied in tank cultivated Gracilaria conferta (Rhodophyta). Electron transport rate (ETR) and biliprotein content were higher under high nutrient supply (HNS), obtained from fishpond effluents, compared to low nutrient supply (LNS), in contrast to mycosporine-like amino acids (MAAs) dynamic. The high MAA content in LNS-algae could be explained by higher UVR penetration in the thallus and by the competition for the use of nutrients with other processes. Effective quantum yield decreased after short-term exposure to high irradiance whereas full recovery in shade was produced only under slightly heat shock. UVA radiation provoked an additional decrease in photosynthesis under high water temperature. UVB radiation reversed UVA's negative effect mainly with HNS. Results support that nutrient-sufficiency help G. conferta to resist environmental changes as short-term temperature increase.

Preliminary study of the anti-inflammatory activity of hexane extract and fractions from Bursera simaruba (Linneo) Sarg. (Burseraceae) leaves

Bursera simaruba (L.) Sarg. leaves hexane extracts display anti-inflammatory activity on the adjuvant-carrageenan-induced inflammation in rats. In order to isolate and identify the active compounds of the hexane extract, we performed a preliminary phytochemical study and a bioassay-directed fractionation using the carrageenan-induced paw oedema test in mice. From the nine fractions (A-I) obtained, of an initial chromatographic separation, fractions A and E (doses equivalents to 1.50 g dry plant/kg body weight) showed the strongest anti-inflammatory activity comparable to that of the reference drug phenylbutazone (80 mg/kg). The isolation and characterization of 3-methylene-7,11,15-trimethylhexadec-1-ene (neophytadiene) (1), ergost-5-en-3beta-ol (2), 24S-stigmast-5,22E-dien-3beta-ol (3), 24S-stigmast-5-en-3beta-ol (4) and alpha-amyrin (5), from these fractions is reported.

Inhibition of NEMO, the regulatory subunit of the IKK complex, induces apoptosis in high-risk myelodysplastic syndrome and acute myeloid leukemia

In high-risk myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML), blasts constitutively activate the antiapoptotic transcription factor nuclear factor-kappaB (NF-kappaB). Here, we show that this NF-kappaB activation relies on the constitutive activation of the IkappaB kinase (IKK) complex, which is formed by the IKKalpha, IKKbeta and IKKgamma/NF-kappaB essential modulator (NEMO) subunits. A cell-permeable peptide that mimics the leucine zipper subdomain of IKKgamma, thus preventing its oligomerization, inhibited the constitutive NF-kappaB activation and induced apoptotic cell death in a panel of human MDS and AML cell lines (P39, MOLM13, THP1 and MV4-11). Small interfering RNA-mediated knockdown of the p65 NF-kappaB subunit or the three IKK subunits including IKKgamma/NEMO also induced apoptotic cell death in P39 cells. Cell death induced by the IKKgamma/NEMO-antagonistic peptide involved the caspase-independent loss of the mitochondrial transmembrane potential as well as signs of outer mitochondrial membrane permeabilization with the consequent release of cytochrome c, apoptosis-inducing factor and endonuclease G. Primary bone marrow CD34(+) cells from high-risk MDS and AML patients also succumbed to the IKKgamma/NEMO-antagonistic peptide, but not to a mutated control peptide. Altogether, these data indicate that malignant cells in high-risk MDS and AML cells critically depend on IKKgamma/NEMO to survive. Moreover, our data delineate a novel procedure for their therapeutic removal, through inhibition of IKKgamma/NEMO oligomerization.

Anti-inflammatory activity of leaf extract and fractions of Bursera simaruba (L.) Sarg (Burseraceae)

Seeking for new medicinal compounds in plants used in traditional medicine, which grow in Venezuela, we investigated the anti-inflammatory activity of the leaf hexane extract (HE) and several fractions obtained from sp. Bursera simaruba (L.) Sarg. (Indio desnudo) using carrageenan-induced paw edema inflammation. Oral administration of leaf HE as well I (91-100) fraction, and compounds VIII 25-26 and VIII 29, inhibited the carrageenan-induced paw edema with different capacity and time course, over a period of 7h. The anti-inflammatory effect was comparable to that of the reference drug phenylbutazone (80 mg/kg, p.o.). Included in fraction I (91-100), Vitamin E was identified as one of its components and compound VIII 29 was identified as a methyl-beta-peltatin A. The comparison of the anti-inflammatory activity of VIII 29 fraction with the corresponding standard of methyl-beta-peltatin A, suggest that this compound could be one of the active principles involved in the anti-inflammatory activity of Bursera simaruba (L.) Sarg. leave. Our results contribute to the pharmacological support of the use of Bursera simaruba (L.) Sarg. as anti-inflammatory in the ethnomedicinal practice.

Angiotensin II supports sympathetically mediated vasopressor response to footshock-stress

The present study was carried out to assess whether endogenous angiotensin II (Ang II) supports sympathetically mediated cardiovascular response to stress in conscious unrestrained rats, using experimental models in which the renin-angiotensin-system was reduced or blocked. Footshock-stress increased mean arterial pressure (MAP) and heart rate (HR). Inhibition of angiotensin-converting enzyme with captopril or blockade of AT(1)angiotensin receptor with losartan, attenuated vasopressor responses to footshocks, while heart rate response was not altered. Bilateral nephrectomy suppressed vasopressor response as well the elevation of plasma noradrenaline and adrenaline induced by footshocks, and reduced heart rate response. Cardiovascular response to stress in nephrectomised rats was restored by exogenous administration of a subpressor dose of Ang II. Our results demonstrate that in conscious rats cardiovascular response to footshocks is dependent on an active renin-angiotensin system and they indicate that endogenous Ang II supports the sympathetically mediated vasopressor response to footshocks.

Role of endothelin in stress-induced hypertension

In this study we investigated the role of endogenous endothelin in the cardiovascular response to acute stress, ie mild footshocks in conscious rats. Footshock-stress significantly increased mean arterial pressure and heart rate (P < 0.05). Peripheral or intracerebroventricular (IVT) administration of BQ 788, a selective antagonist of ET(B) receptor, did not alter pressor response to footshocks. Intraperitoneal injections of BQ 123 (1 mg/kg), a selective antagonist of the ET(A)-receptor, had a tendency to decrease, while BQ 123 (203 ng/5 microl) IVT administration significantly reduced the pressor response to footshocks (-12 mm Hg, P < 0.001). Neither ET(A) nor ET(B) antagonists, when injected centrally or peripherally, altered basal blood pressure or heart rate. Our results may indicate a role of brain endothelin in the sympathetic mediated cardiovascular response to stress, via stimulation of ET(A) receptor.

Modelling perspectives on aging: can mathematics help us stay young?

We survey several types of mathematical models that keep track of age distributions in a population, or follow some aspects of aging, such as loss of replicative potential of stem cells. The properties of a class of linear models of this type are discussed and compared. We illustrate the applicability of such models with a simple example based on hypothetical stem cell dynamics developed to address age-related telomere loss in the human granulocyte pool. We then describe the contrasting behaviour of nonlinear systems. Examples are drawn from the class of "dynamical diseases" to illustrate some of the aspects of nonlinear systems. Applications of these, and other models to the problems of aging and replicative aging are discussed.

Effect of adrenomedullin receptor and calcitonin gene-related peptide receptor antagonists on centrally mediated adrenomedullin renal action

To determine pharmacological specificity of intracerebroventricular (IVT) administration of adrenomedullin (AM) on water and sodium excretion, studies were performed in rats pretreated with AM (22-52), a putative AM-receptor antagonist or CGRP(8-37), a ligand that preferentially antagonizes the CGRP(1)-receptor subtype. In addition, the effects of IVT injection of calcitonin-gene-related peptide (CGRP) on urinary water and electrolyte excretion was assessed. Intracerebroventricular administration of rat adrenomedullin to conscious hydrated rats resulted in a significant increase in urinary volume and sodium excretion during the 6-h period of urine collection and was most effective at 3 and 6 h. Although less effective than AM, central administration of CGRP induced diuresis and natriuresis. Pretreatment with AM (22-52) or CGRP(8-37) significantly suppressed the diuretic and natriuretic effect of IVT-AM. These data suggest that both CGRP(1) and AM receptors are involved in the centrally mediated diuretic and natriuretic action of the AM. Our results provide evidence supporting the hypothesis that endogenous AM plays a role in the central nervous control of fluid and electrolyte homeostasis.

A prospective comparison of three heat preservation methods for patients undergoing hypothermic cardiopulmonary bypass

OBJECTIVE

To prospectively compare 3 methods of body heat preservation in patients undergoing surgery requiring the use of hypothermic cardiopulmonary bypass (CPB).

DESIGN

Prospective, randomized, and nonblinded.

SETTING

University teaching hospital.

PARTICIPANTS

Adult cardiac surgery patients (n = 101).

INTERVENTIONS

Subjects were randomly assigned to 1 of 3 treatment groups: Group 1 (n = 33) used a fluid-filled warming blanket, group 2 (n = 31) used a heated and humidified breathing circuit, and group 3 (n = 37) used intravenous fluid warmers for the administration of all fluids. Treatments started on separation from CPB and concluded at the end of the intraoperative experience. Anesthetic technique, minute ventilation, conduct of CPB, and room temperature in the operating room were standardized.

MEASUREMENTS AND MAIN RESULTS

Blood temperature was measured at its nadir on CPB, on separation from CPB, and just before departure from the operating room. No differences were found among groups for CPB duration, coldest venous temperature on CPB, rewarming time, rate of rewarming, room temperature, or blood temperature on separation from CPB. There were no significant differences found in post-CPB temperature afterdrop among groups.

CONCLUSIONS

This study suggests that there is no statistically significant disparity in the effectiveness of these 3 intraoperative heat preservation methods. Ease of use and cost-effectiveness should guide the choice of warming method post-CPB.

Synthesis and theoretical study of 2-amino-2,3,3a,4,5,6-hexahydro-1H-phenalene and its biological evaluation on central dopaminergic system

Compound 2 considered as a rigid non-hydroxylated 2-amino tetralin was synthesized and biologically evaluated. Central administration of compound 2 (50 microg or 100 microg/10 microl) induced a reduction in urinary sodium and potassium excretion at 3 and 6 h of urine collection. We speculate that compound 2 may be acting as a dopamine receptor antagonist.

Complete lack of NF-kappaB activity in IKK1 and IKK2 double-deficient mice: additional defect in neurulation

NF-kappaB activity is induced by cytokines, stress, and pathogens. IKK1 and IKK2 are critical IkappaB kinases in NF-kappaB activation. In this study mice lacking IKK1 and IKK2 died at E12. Additional defect in neurulation associated with enhanced apoptosis in the neuroepithelium was also observed. MEF cells from IKK1(-/-)/IKK2(-/-) embryos did not respond to NF-kappaB inducers. Upon crossing with kappaB-lacZ transgenic mice, double-deficient embryos also lost lacZ transgene expression in vascular endothelial cells during development. Our data suggest that IKK1 and IKK2 are essential for NF-kappaB activation in vivo and have an important role in protecting neurons against excessive apoptosis during development.

Diuretic and natriuretic action of adrenomedullin administered intracerebroventricularly in conscious rats

Intracerebroventricular administration of rat adrenomedullin (AM) to conscious hydrated or salt-loaded rats, resulted in a significant increase in urinary volume. The diuretic effect of adrenomedullin occurred during the 6-h period of urine collection and was most effective during the 3 and 6 h. Most remarkably, AM given IVT induced a dose-related increase in urinary sodium excretion at all periods of urine collection. In addition, AM induced significant kaliuresis. Our results strongly suggest that AM may play a significant role in the central regulation of fluid and electrolyte homeostasis, and that its diuretic and natriuretic effect may be, at least in part, centrally mediated.

Raf induces NF-kappaB by membrane shuttle kinase MEKK1, a signaling pathway critical for transformation

NF-kappaB is regulated by inhibitor proteins (IkappaBs), which retain NF-kappaB in the cytoplasm. Signal-induced phosphorylation by the IkappaB-kinase complex containing the IkappaB-kinases 1 and 2 (IKK-1/2 or IKK-alpha/beta) and subsequent degradation of the IkappaB proteins are prerequisites for NF-kappaB activation. Many signals induce NF-kappaB, one of them being oncogenic Raf kinase. We investigated whether NF-kappaB induction is critical for Raf-mediated transformation. Here, we demonstrate that inhibition of NF-kappaB interferes with transformation by the Raf-oncogene, and we characterized the mechanism of NF-kappaB induction by activated Raf kinase and the tumor promoter phorbol 12-myristate 13-acetate (PMA). NF-kappaB activation by PMA and Raf critically depends on the IkappaB-kinase complex, most notably on IKK-2. A major signaling pathway induced by Raf is the mitogenic cytoplasmic kinase cascade. However, different inhibitors of this cascade do not affect PMA- and Raf-mediated NF-kappaB activation. Raf does not phosphorylate the IkappaB-kinase proteins directly. Raf rather synergizes with another membrane shuttle kinase MEKK1, and Raf-mediated activation of NF-kappaB is blocked by a dominant negative form of MEKK1. These results suggest that Raf induction of NF-kappaB is relayed by MEKK1, but not by the classical mitogenic cytoplasmic kinase cascade.

Angiotensin AT(2) receptors mediate vasodepressor response to footshock in rats. Role of kinins, nitric oxide and prostaglandins

Footshocks increased mean arterial pressure and heart rate. Systemic administration of losartan, a specific angiotensin AT(1) receptor antagonist, not only inhibited the pressor response to footshocks, but also resulted in vasodepression. Administration of 1-[[4-(dimethylamino)3-methylphenyl]methyl]-5 (diphenylacetyl)-4,5,6, 7-tetrahydro-1H imidazol (4,5-c] pyridine-6-carboxilic acid, ditrifluoro acetatemonohydrate (PD 123319), a specific angiotensin AT(2) receptor antagonist, did not alter the hemodynamic response to footshocks. Simultaneous blockade of angiotensin AT(1) and AT(2) receptors by combined administration of losartan and PD 123319, eliminated the vasodepressor response to footshocks unmasked in losartan-pretreated rats. Saralasin, a non-specific angiotensin receptor antagonist, abolished the cardiovascular response to footshocks similarly like the losartan+PD 123319 treatment. Our data suggest that the vasodepressor response to footshocks in the presence of an angiotensin AT(1) receptor antagonist is triggered by activation of angiotensin AT(2) receptors. We studied the role of kinins, nitric oxide and prostaglandins in the vasodepressor response observed after footshocks. The decrease in mean arterial pressure observed after footshocks in losartan-treated rats was blunted by icatibant (HOE 140), N(G)-nitro-L-arginine-methyl ester (L-NAME) or indomethacin, indicating that kinins, nitric oxide and prostaglandins appear to be involved in the pressure response to footshocks during angiotensin AT(1) receptor blockade.

Role of bradykinins and nitric oxide in the AT2 receptor-mediated hypotension

Footshocks increases mean arterial pressure and heart rate. Systemic or intracerebroventricular (IVT) administration of losartan, a specific angiotensin AT1 receptor antagonist, not only inhibited the pressor response to footshocks but resulted in vasodepression. Peripheral or IVT administration of PD 123319, a specific angiotensin AT2 receptor antagonist, did not alter the haemodynamic response to footshocks. However, simultaneous blockade of angiotensin AT1 and AT2 receptors by combined systemic or central administration of losartan and PD 12319, eliminated the vasodepressor response to footshocks unmasked in losartan pretreated rats. Our data suggest that activation of peripheral or brain angiotensin AT2 receptor mediated the vasodepressor response to footshocks in the presence of angiotensin AT1 receptor antagonist. We studied the role of kinins and nitric oxide in the vasodepressor response observed after footshocks. The decrease in mean arterial pressure observed after footshocks in losartan treated rats was blunted by systemic or IVT administration of icatibant (HOE 140) or N(G)-nitro-L-arginine-methyl ester, indicating that peripheral or brain kinins and nitric oxide are involved in the hypotensor response to footshocks during angiotensin AT1 receptor blockade. Our results suggest a role for angiotensin AT2 receptor in the regulation of arterial blood pressure, possibly through the release of vasodilator autacoids such as bradykinins and nitric oxide.

Renin-angiotensin-aldosterone system in pregnancy-induced hypertension

Angiotensin-converting enzyme (ACE) and aldosterone concentration were measured in the plasma of 32 pregnant women with normal blood pressure or with pregnancy-induced hypertension (PIH). Mean arterial pressure (MAP) in PIH women was significantly higher than in normotensive pregnant women. Plasma ACE activity and aldosterone concentration in 17 PIH patients was significantly lower than their normotensive counterparts (15 cases). Mean arterial pressure was negatively correlated with the level of plasma ACE activity and with plasma aldosterone concentration in all pregnant women. Our results indicate that the circulating renin-angiotensin-aldosterone system is suppressed in pregnancy-induced hypertension.

Brain AT(2) receptor mediate vasodepressor response to footshocks: role of kinins and nitric oxide

In the present study the role of brain AT(2) receptor in the cardiovascular response to stress was investigated in conscious rats. Footshock-stress increased mean arterial pressure (MAP) and heart rate (p < 0.0001). Intracerebroventricular (i.c.v.) administration of losartan (100 microg/5 microl), a specific angiotensin AT(1) receptor antagonist, not only attenuated the pressor response to footshocks, but also resulted in a consistent vasodepressor response (-10 mmHg, p < 0.02). Meanwhile, heart rate response was not altered. Given alone, PD 123319 (3 microg/5 microl, i.c.v.), a specific angiotensin AT(2) receptor antagonist, did not alter the hemodynamic response to footshocks. However, simultaneous block of brain AT(1) and AT(2) receptors by combined administration of losartan and PD 12319, eliminated the vasodepressor response unmasked after footshocks in rats i.c.v.-pretreated with losartan alone. In addition, we studied the role of brain kinins and nitric oxide (NO) in the vasodepressor response observed after footshocks in losartan i.c.v.-treated rats. Intracerebroventricular administration of icatibant (20 pmol/5 microl), a selective B(2) receptor antagonist, or N(G)-nitro-L-arginine methyl ester (100 microg/5 microl), a selective NO-synthase inhibitor, abolished the vasodepressor response to footshocks in losartan-treated rats. Our data suggest that the vasodepressor response to footshocks in the presence of AT(1) antagonist is triggered by activation of AT(2) receptor. Brain NO and kinins appear to contribute in this effect.

Endothelin-1 stimulates phosphoinositide hydrolysis in the rat pineal gland

The presence of functional endothelin receptors and their signal transduction mechanism has not been determined so far in the pineal gland. We examined the effect of endothelin-1 (ET-1) on phosphoinositide turnover in whole pineal gland. Endothelin-1 increased monophosphate accumulation in a dose-dependent manner. The phosphoinositide (PI) response elicited by ET-1 was dependent on the presence of extracellular Ca (++) since its chelation resulted in a marked decrease in ET-1-stimulated InsP(1) accumulation. On the contrary, phosphoinositide hydrolysis was not changed by the calcium blocker amlodipine. ET-1 induced PI breakdown was inhibited by neomycin, an inhibitor of phospholipase C. However, mastoparan 7, a G protein activator via Gi/Go s timulation, did not alter ET-1-induced InsP(1) accumulation. Our data indicate that stimulation of PI turnover constitutes one of the signaling pathways of ET in rat pineal gland through the stimulation of a receptor-coupled phospholipase C. And they demonstrate, for the first time, the presence of functional binding sites for endothelin in the pineal gland.

Listeriolysin O-dependent activation of endothelial cells during infection with Listeria monocytogenes: activation of NF-kappa B and upregulation of adhesion molecules and chemokines

The facultative intracellular bacterium Listeria monocytogenes is an invasive pathogen that crosses the vascular endothelium and disseminates to the placenta and the central nervous system. Its interaction with endothelial cells is crucial for the pathogenesis of listeriosis. By infecting in vitro human umbilical vein endothelial cells (HUVEC) with L. monocytogenes, we found that wild-type bacteria induced the expression of the adhesion molecules (ICAM-1 and E-selectin), chemokine secretion (IL-8 and monocyte chemotactic protein-1) and NF-kappa B nuclear translocation. The activation of HUVEC required viable bacteria and was abolished in prfA-deficient mutants of L. monocytogenes, suggesting that virulence genes are associated with endothelial cell activation. Using a genetic approach with mutants of virulence genes, we found that listeriolysin O (LLO)-deficient mutants inactivated in the hly gene did not induce HUVEC activation, as opposed to mutants inactivated in the other virulence genes. Adhesion molecule expression, chemokine secretion and NF-kappa B activation were fully restored by a strain of Listeria innocua transformed with the hly gene encoding LLO. The relevance in vivo of endothelial cell activation for listerial pathogenesis was investigated in transgenic mice carrying an NF-kappa B-responsive lacZ reporter gene. NF-kappa B activation was visualized by a strong lacZ expression in endothelial cells of capillaries of mice infected with a virulent haemolytic strain, but was not seen in those infected with a non-haemolytic isogenic mutant. Direct evidence that LLO is involved in NF-kappa B activation in transgenic mice was provided by injecting intravenously purified LLO, thus inducing stimulation of NF-kappa B in endothelial cells of blood capillaries. Our results demonstrate that functional listeriolysin O secreted by bacteria contributes as a potent inflammatory stimulus to inducing endothelial cell activation during the infectious process.

Nitric oxide/cGMP mediates the spasmolytic action of 3,4'-dihydroxy-5,5'-dimethoxybibenzyl from Scaphyglottis livida

Five aromatic compounds, 3,4'-dihydroxy-5,5'-dimethoxybibenzyl (1), batatasin III (2), coelonin (3), 3,7-dihydroxy-2,4-dimethoxyphenanthrene (4), and 3,7-dihydroxy-2,4,8-trimethoxyphenanthrene (5) were isolated from the orchid Scaphyglottis livida (Lindley) Schltr. Compounds 1-5 induced a concentration-dependent inhibition of the spontaneous contractions of the rat ileum with potencies comparable or higher to that of papaverine. The relaxation evoked by compounds 1-4 was blocked by L-NAME, an inhibitor of nitric oxide synthase. It was also demonstrated that 1 increased cyclic GMP content in rat ileum rings. Compound 1-induced elevation of cGMP was inhibited by L-NAME and ODQ, inhibitors of nitric oxide synthase and soluble guanylyl cyclase, respectively. These results indicate that nitric oxide/cGMP formation constitute the signaling pathway in the spasmolytic action of compound 1.

Gastrovascular Circulation in an Octocoral: Evidence of Significant Transport of Coral and Symbiont Cells

The gastrovascular system in the Red Sea soft coral Parerythropodium fulvum fulvum comprises two interconnected networks of canals filled with fluid and circulating cells. The first network is composed of narrow canals (50-80 {mu}m in width) located below the upper ectodermal layer; the second network includes larger canals (300-500 {mu}m in width) that are located deeper in the coral tissue. Particle movement in the second network is faster than in the superficial network, but in both, coral cells with and without healthy zooxanthellae circulate freely. To investigate the movement of metabolites and cellular components within the colony, coral fragments were exposed to 14C-labeled seawater for 24 h in the laboratory and in situ under saturating photosynthetic photon flux and then grafted back to their original colonies. Grafts fused after 24 h. In the laboratory experiment, up to 45% of the fixed 14C was translocated to the unlabeled colony within 48 h after fusion. In the in situ experiment, significant translocation of labeled materials occurred at the furthest parts of the colonies, 390 mm away from the fusion line, in 24 h. Even though the amount of labeling varied between colonies, labeled material spread throughout all the unlabeled parts. It thus appears that the gastrovascular system in Parerythropodium fulvum fulvum functions as an effective circulatory apparatus for fast translocation of organic compounds and cellular components within the colony.

Thioperamide, a histamine H3-receptor blocker, facilitates vasopressor response to footshocks

OBJECTIVE AND DESIGN

We assessed the functional role of the histamine H3-receptor in conscious intact rats during activation of the sympathoadrenal axis.

MATERIAL

Male Sprague-Dawley rats, with or without cerebroventricular cannula, were subjected to mild footshocks and mean arterial pressure (MAP) and heart rate were determined using a tail-cuff plethysmograph.

TREATMENTS

Saline, phentolamine (3 mg/kg, i.p.), (R)-alphafluoromethylhistidine (AFMH) (100 mg/kg, i.p., or 100 microg/5 microl, i.v.t.), (R)-alphamethylhistamine (AMH) (2 mg/kg, i.p. or 100 microg/5 microl, i.v.t.), thioperamide (THIO) (1 or 2 mg/kg, i.p., or 100 microg/5 microl, i.v.t.), mepyramine (10 mg/kg, i.p.), cimetidine (2 mg/kg, i.p.).

METHODS

Urinary catecholamines were determined by fluorometry. Statistical differences between experimental groups were evaluated by Student's t-test or one-way ANOVA.

RESULTS

Footshocks increased both MAP and heart rate. The vasopressor response to footshocks was facilitated (p < 0.001) by i.p. administration of AFMH, a histidine decarboxylase inhibitor, or THIO, a H3-receptor antagonist, but not by i.v.t. injection of these drugs. AMH, a H3-receptor agonist, given i.p., decreased the vasopressor response to footshocks (p < 0.001). This action of AMH was abolished by THIO but not by mepyramine or cimetidine. The MAP response to exogenous norepinephrine was not altered by i.p. administration of either AFMH or THIO.

CONCLUSIONS

Our results demonstrate an involvement of peripheral histamine H3 prejunctional receptors in the inhibitory modulation of peripheral noradrenergic responses during stress.