Rho-associated kinase regulates Langerhans cell morphology and responsiveness to tissue damage

Skin damage requires efficient immune cell responses to restore organ function. Epidermal-resident immune cells known as Langerhans cells use dendritic protrusions to surveil the skin microenvironment, which contains keratinocytes and peripheral axons. The mechanisms governing Langerhans cell dendrite dynamics and responses to tissue damage are poorly understood. Using skin explants from adult zebrafish, we show that Langerhans cells maintain normal surveillance following axonal degeneration and use their dendrites to engulf small axonal debris. By contrast, a ramified-to-rounded shape transition accommodates the engulfment of larger keratinocyte debris. We find that Langerhans cell dendrites are populated with actin and sensitive to a broad-spectrum actin inhibitor. We show that Rho-associated kinase (ROCK) inhibition leads to elongated dendrites, perturbed clearance of large debris, and reduced Langerhans cell migration to epidermal wounds. Our work describes the dynamics of Langerhans cells and involvement of the ROCK pathway in immune cell responses.

Dendritic atoh1a+ cells serve as transient intermediates during zebrafish Merkel cell development and regeneration

Sensory cells often adopt specific morphologies that aid in the detection of external stimuli. Merkel cells encode gentle touch stimuli in vertebrate skin and adopt a reproducible shape characterized by spiky, actin-rich microvilli that emanate from the cell surface. The mechanism by which Merkel cells acquire this stereotyped morphology from basal keratinocyte progenitors is unknown. Here, we establish that dendritic Merkel cells (dMCs) express atonal homolog 1a (atoh1a), extend dynamic filopodial processes, and arise in transient waves during zebrafish skin development and regeneration. We find that dMCs share molecular similarities with both basal keratinocytes and Merkel cells, yet display mesenchymal-like behaviors, including local cell motility and proliferation within the epidermis. Furthermore, dMCs can directly adopt the mature, microvilliated Merkel cell morphology through substantial remodeling of the actin cytoskeleton. Loss of Ectodysplasin A signaling alters the morphology of dMCs and Merkel cells within specific skin regions. Our results show that dMCs represent an intermediate state in the Merkel cell maturation program and identify Ectodysplasin A signaling as a key regulator of Merkel cell morphology.

Rho-associated kinase regulates Langerhans cell morphology and responsiveness to tissue damage

Skin is often the first physical barrier to encounter invading pathogens and physical damage. Damage to the skin must be resolved quickly and efficiently to maintain organ homeostasis. Epidermal-resident immune cells known as Langerhans cells use dendritic protrusions to dynamically surveil the skin microenvironment, which contains epithelial keratinocytes and somatosensory peripheral axons. The mechanisms governing Langerhans cell dendrite dynamics and responses to tissue damage are not well understood. Using skin explants from adult zebrafish, we show that Langerhans cells maintain normal surveillance activity following axonal degeneration and use their dynamic dendrites to engulf small axonal debris. By contrast, a ramified-to-rounded shape transition accommodates the engulfment of larger keratinocyte debris. We find that Langerhans cell dendrites are richly populated with actin and sensitive to a broad spectrum actin inhibitor. We further show that Rho-associated kinase (ROCK) inhibition leads to elongated dendrites, perturbed clearance of large debris, and reduced Langerhans cell migration to tissue-scale wounds. Altogether, our work describes the unique dynamics of Langerhans cells and involvement of the ROCK pathway in immune cell responses to damage of varying magnitude.

Zebrafish cutaneous injury models reveal that Langerhans cells engulf axonal debris in adult epidermis

Somatosensory neurons extend enormous peripheral axons to the skin, where they detect diverse environmental stimuli. Somatosensory peripheral axons are easily damaged due to their small caliber and superficial location. Axonal damage results in Wallerian degeneration, creating vast quantities of cellular debris that phagocytes must remove to maintain organ homeostasis. The cellular mechanisms that ensure efficient clearance of axon debris from stratified adult skin are unknown. Here, we established zebrafish scales as a tractable model to study axon degeneration in the adult epidermis. Using this system, we demonstrated that skin-resident immune cells known as Langerhans cells engulf the majority of axon debris. In contrast to immature skin, adult keratinocytes did not significantly contribute to debris removal, even in animals lacking Langerhans cells. Our study establishes a powerful new model for studying Wallerian degeneration and identifies a new function for Langerhans cells in maintenance of adult skin homeostasis following injury. These findings have important implications for pathologies that trigger somatosensory axon degeneration.

Dermal appendage-dependent patterning of zebrafish atoh1a+ Merkel cells

Touch system function requires precise interactions between specialized skin cells and somatosensory axons, as exemplified by the vertebrate mechanosensory Merkel cell-neurite complex. Development and patterning of Merkel cells and associated neurites during skin organogenesis remain poorly understood, partly due to the in utero development of mammalian embryos. Here, we discover Merkel cells in the zebrafish epidermis and identify Atonal homolog 1a (Atoh1a) as a marker of zebrafish Merkel cells. We show that zebrafish Merkel cells derive from basal keratinocytes, express neurosecretory and mechanosensory machinery, extend actin-rich microvilli, and complex with somatosensory axons, all hallmarks of mammalian Merkel cells. Merkel cells populate all major adult skin compartments, with region-specific densities and distribution patterns. In vivo photoconversion reveals that Merkel cells undergo steady loss and replenishment during skin homeostasis. Merkel cells develop concomitant with dermal appendages along the trunk and loss of Ectodysplasin signaling, which prevents dermal appendage formation, reduces Merkel cell density by affecting cell differentiation. By contrast, altering dermal appendage morphology changes the distribution, but not density, of Merkel cells. Overall, our studies provide insights into touch system maturation during skin organogenesis and establish zebrafish as an experimentally accessible in vivo model for the study of Merkel cell biology.

Osteoblasts pattern endothelium and somatosensory axons during zebrafish caudal fin organogenesis

Skeletal elements frequently associate with vasculature and somatosensory nerves, which regulate bone development and homeostasis. However, the deep, internal location of bones in many vertebrates has limited in vivo exploration of the neurovascular-bone relationship. Here, we use the zebrafish caudal fin, an optically accessible organ formed of repeating bony ray skeletal units, to determine the cellular relationship between nerves, bones and endothelium. In adult zebrafish, we establish the presence of somatosensory axons running through the inside of the bony fin rays, juxtaposed with osteoblasts on the inner hemiray surface. During development we show that the caudal fin progresses through sequential stages of endothelial plexus formation, bony ray addition, ray innervation and endothelial remodeling. Surprisingly, the initial stages of fin morphogenesis proceed normally in animals lacking either fin endothelium or somatosensory nerves. Instead, we find that sp7+ osteoblasts are required for endothelial remodeling and somatosensory axon innervation in the developing fin. Overall, this study demonstrates that the proximal neurovascular-bone relationship in the adult caudal fin is established during fin organogenesis and suggests that ray-associated osteoblasts pattern axons and endothelium.

Transparent Touch: Insights From Model Systems on Epidermal Control of Somatosensory Innervation

Somatosensory neurons (SSNs) densely innervate our largest organ, the skin, and shape our experience of the world, mediating responses to sensory stimuli including touch, pressure, and temperature. Historically, epidermal contributions to somatosensation, including roles in shaping innervation patterns and responses to sensory stimuli, have been understudied. However, recent work demonstrates that epidermal signals dictate patterns of SSN skin innervation through a variety of mechanisms including targeting afferents to the epidermis, providing instructive cues for branching morphogenesis, growth control and structural stability of neurites, and facilitating neurite-neurite interactions. Here, we focus onstudies conducted in worms (Caenorhabditis elegans), fruit flies (Drosophila melanogaster), and zebrafish (Danio rerio): prominent model systems in which anatomical and genetic analyses have defined fundamental principles by which epidermal cells govern SSN development.

A conserved morphogenetic mechanism for epidermal ensheathment of nociceptive sensory neurites

Interactions between epithelial cells and neurons influence a range of sensory modalities including taste, touch, and smell. Vertebrate and invertebrate epidermal cells ensheath peripheral arbors of somatosensory neurons, including nociceptors, yet the developmental origins and functional roles of this ensheathment are largely unknown. Here, we describe an evolutionarily conserved morphogenetic mechanism for epidermal ensheathment of somatosensory neurites. We found that somatosensory neurons in Drosophila and zebrafish induce formation of epidermal sheaths, which wrap neurites of different types of neurons to different extents. Neurites induce formation of plasma membrane phosphatidylinositol 4,5-bisphosphate microdomains at nascent sheaths, followed by a filamentous actin network, and recruitment of junctional proteins that likely form autotypic junctions to seal sheaths. Finally, blocking epidermal sheath formation destabilized dendrite branches and reduced nociceptive sensitivity in Drosophila. Epidermal somatosensory neurite ensheathment is thus a deeply conserved cellular process that contributes to the morphogenesis and function of nociceptive sensory neurons.

Humans and other animals perceive and interact with the outside world through their sensory nervous system. Nerve cells, acting as the body’s ‘telegraph wires’, convey signals from sensory organs – like the eyes – to the brain, which then processes this information and tells the body how to respond. There are different kinds of sensory nerve cells that carry different types of information, but they all associate closely with the tissues and organs they connect to the brain.

Human skin contains sensory nerve cells, which underpin our senses of touch and pain. There is a highly specialized, complex connection between some of these nerve cells and cells in the skin: the skin cells wrap tightly around the nerve cells’ free ends, forming sheath-like structures. This ‘ensheathment’ process happens in a wide range of animals, including those with a backbone, like fish and humans, and those without, like insects.

Ensheathment is thought to be important for the skin’s nerve cells to work properly. Yet it remains unclear how or when these connections first appear. Jiang et al. therefore wanted to determine the developmental origins of ensheathment and to find out if these were also similar in animals with and without backbones.

Experiments using fruit fly and zebrafish embryos revealed that nerve cells, not skin cells, were responsible for forming and maintaining the sheaths. In embryos where groups of sensory nerve cells were selectively killed – either using a laser or by making the cells produce a toxin – ensheathment did not occur. Further studies, using a variety of microscopy techniques, revealed that the molecular machinery required to stabilize the sheaths was similar in both fish and flies, and therefore likely to be conserved across different groups of animals. Removing sheaths in fly embryos led to nerve cells becoming unstable; the animals were also less sensitive to touch. This confirmed that ensheathment was indeed necessary for sensory nerve cells to work properly.

By revealing how ensheathment first emerges, these findings shed new light on how the sensory nervous system develops and how its activity is controlled. In humans, skin cells ensheath the nerve cells responsible for sensing pain. A better understanding of how ensheathments first arise could therefore lead to new avenues for treating chronic pain and related conditions.

Cell interactions and patterned intercalations shape and link epithelial tubes in C. elegans

Many animal organs are composed largely or entirely of polarized epithelial tubes, and the formation of complex organ systems, such as the digestive or vascular systems, requires that separate tubes link with a common polarity. The Caenorhabditis elegans digestive tract consists primarily of three interconnected tubes—the pharynx, valve, and intestine—and provides a simple model for understanding the cellular and molecular mechanisms used to form and connect epithelial tubes. Here, we use live imaging and 3D reconstructions of developing cells to examine tube formation. The three tubes develop from a pharynx/valve primordium and a separate intestine primordium. Cells in the pharynx/valve primordium polarize and become wedge-shaped, transforming the primordium into a cylindrical cyst centered on the future lumenal axis. For continuity of the digestive tract, valve cells must have the same, radial axis of apicobasal polarity as adjacent intestinal cells. We show that intestinal cells contribute to valve cell polarity by restricting the distribution of a polarizing cue, laminin. After developing apicobasal polarity, many pharyngeal and valve cells appear to explore their neighborhoods through lateral, actin-rich lamellipodia. For a subset of cells, these lamellipodia precede more extensive intercalations that create the valve. Formation of the valve tube begins when two valve cells become embedded at the left-right boundary of the intestinal primordium. Other valve cells organize symmetrically around these two cells, and wrap partially or completely around the orthogonal, lumenal axis, thus extruding a small valve tube from the larger cyst. We show that the transcription factors DIE-1 and EGL-43/EVI1 regulate cell intercalations and cell fates during valve formation, and that the Notch pathway is required to establish the proper boundary between the pharyngeal and valve tubes.

Tubes composed of epithelial cells are universal building blocks of animal organs, and complex organs typically contain multiple interconnected tubes, such as in the digestive tract or vascular system. The nematode Caenorhabditis elegans provides a simple genetic system to study how tubes form and link. Understanding these events provides insight into basic biology, and can inform engineering strategies for building or repairing cellular tubes. A small tube called the valve connects the two major tubular organs of the nematode digestive tract, the pharynx and intestine. The pharynx and valve form from the same primordium, while the intestine forms from a separate primordium. Cells in each primordium polarize around a central axis, and valve formation involves connecting these axes. Using live imaging, we show that valve cells initially resemble other pharyngeal cells, but undergo additional and extensive intercalations around the lumenal axis, effectively squeezing a small tube from the larger primordium. Valve cells develop the same polarity axis as intestinal cells, and we show that this depends on interactions with the intestinal cells. We show that valve formation involves dynamic changes in the localization of adhesive proteins, and identify transcription factors that play a role in valve cell specification and intercalation.

Laminin is required to orient epithelial polarity in the C. elegans pharynx

The development of many animal organs involves a mesenchymal to epithelial transition, in which cells develop and coordinate polarity through largely unknown mechanisms. The C. elegans pharynx, which is an epithelial tube in which cells polarize around a central lumen, provides a simple system with which to understand the coordination of epithelial polarity. We show that cell fate regulators cause pharyngeal precursor cells to group into a bilaterally symmetric, rectangular array of cells called the double plate. The double plate cells polarize with apical localization of the PAR-3 protein complex, then undergo apical constriction to form a cylindrical cyst. We show that laminin, but not other basement membrane components, orients the polarity of the double plate cells. Our results provide in vivo evidence that laminin has an early role in cell polarity that can be distinguished from its later role in basement membrane integrity.

The RNAseIII enzyme Drosha is critical in T cells for preventing lethal inflammatory disease

MicroRNAs (miRNAs) are implicated in the differentiation and function of many cell types. We provide genetic and in vivo evidence that the two RNaseIII enzymes, Drosha and Dicer, do indeed function in the same pathway. These have previously been shown to mediate the stepwise maturation of miRNAs (Lee, Y., C. Ahn, J. Han, H. Choi, J. Kim, J. Yim, J. Lee, P. Provost, O. Radmark, S. Kim, and V.N. Kim. 2003. Nature. 425:415–419), and genetic ablation of either within the T cell compartment, or specifically within Foxp3⁺ regulatory T (T reg) cells, results in identical phenotypes. We found that miRNA biogenesis is indispensable for the function of T reg cells. Specific deletion of either Drosha or Dicer phenocopies mice lacking a functional Foxp3 gene or Foxp3⁺ cells, whereas deletion throughout the T cell compartment also results in spontaneous inflammatory disease, but later in life. Thus, miRNA-dependent regulation is critical for preventing spontaneous inflammation and autoimmunity.

Notch signaling and morphogenesis of single-cell tubes in the C. elegans digestive tract

During organogenesis of the C. elegans digestive system, epithelial cells within a cyst-like primordium develop diverse shapes through largely unknown mechanisms. We here analyze two adjacent, dorsal epithelial cells, called pm8 and vpi1, that remodel their shapes and apical junctions to become donut-shaped, or toroidal, single-cell tubes. pm8 and vpi1 delaminate from the dorsal cyst epithelium and migrate ventrally, across the midline of the cyst, on a transient tract of laminin. pm8 appears to encircle the midline by wrapping around finger-like projections from neighboring cells. Finally, pm8 and vpi1 self-fuse to become toroids by expressing AFF-1 and EFF-1, two fusogens that are each sufficient to promote crossfusion between other cell types. Notch signaling in pm8 induces AFF-1 expression, while simultaneously repressing EFF-1 expression; vpi1 expresses EFF-1 independent of Notch. Thus, the adjacent pm8 and vpi1 cells express different fusogens, allowing them to self-fuse into separate, single-cell tubes while avoiding crossfusion.

Development and field testing of a real-time PCR assay for cylindrospermopsin-producing cyanobacteria

AIMS

To develop and test a real-time PCR assay to detect and quantify genes specific to Cylindrospermopsis sp. and cylindrospermopsin-producing cyanobacteria.

METHOD AND RESULTS

A duplex real-time PCR assay was developed that targets a cylindrospermopsin-specific and Cylindrospermopsis raciborskii-specific DNA sequence. The C. raciborskii-specific sequence was based on the rpoC1 DNA-dependent RNA polymerase gene, whilst the cylindrospermopsin-specific sequence was selected by surveying an extensive number of potential cylindrospermopsin-producing cyanobacterial strains for genes implicated in toxin production, aoaA, aoaB and aoaC. In toxic strains, sequences of each of these three genes were always present; whilst in nontoxic strains the distribution of these sequences was patchy, resulting in what are likely to be natural deletion mutants. The real-time assay was optimized on a fixed and portable device, with results indicating that the reliable limit of detection for the assay was 100 copies per reaction or 1000 cells ml(-1) for both target sequences on both devices. In routine environmental samples enumerated by microscopy, the assay results were positive for all samples where C. raciborskii cells were observed at >1000 cells ml(-1) and negative in 15 samples where no C. raciborskii cells were observed. In field samples, the number of copies of the rpoC1 sequence more closely approximated the number of cells enumerated by microscopy, the number of copies of the pks sequence and detection of the toxin-specific sequence matched the results of toxin testing.

CONCLUSIONS

The duplex real-time PCR assay was a sensitive and rapid method for detecting potential cylindrospermopsin-producing cyanobacteria in the laboratory or in the field. The observation of probable natural deletion mutants provides further evidence that the aoaA, aoaB and aoaC genes are involved in toxin production.

SIGNIFICANCE AND IMPACT OF THE STUDY

This assay provides a new monitoring capability for tracking cylindrospermopsin-producing cyanobacteria that are an emerging threat to water quality.

Rapid preparation of cyanobacterial DNA for real-time PCR analysis

AIMS

To develop a rapid preparation method for real-time PCR analysis of cyanobacteria from cultures or field samples.

METHODS AND RESULTS

Field samples and cultures containing Anabaena circinalis, Cylindrospermopsis raciborskii or Microcystis aeruginosa were subjected to three cell disruption treatments: (i) heating during thermocycling, (ii) microwave irradiation in the presence of detergent and (iii) probe sonication. Treated samples were directly added to the PCR reaction and analysed on two different real-time devices. A statistically significant difference was evident in the cycle thresholds for each of the treatments in all but one culture and one environmental sample, sonication and microwave treatments performing better than direct addition. The microwave treatment was also compared to the Qiagen DNA Mini kit and performance was equivalent when treated samples were analysed as above.

CONCLUSIONS

Whilst microwave treatment was slightly less effective than probe sonication across all samples, it was more amenable to processing multiple samples and significantly better than heat treating the sample during thermocycling.

SIGNIFICANCE AND IMPACT OF THE STUDY

The microwave method described here is a simple, rapid and effective preparation method for cyanobacterial DNA that can be easily deployed in the field, making the most of the speed and flexibility offered by fixed and portable real-time PCR devices.

G protein-coupled receptor 83 is dispensable for the development and function of regulatory T cells

Global analyses of gene expression in regulatory T (Treg) cells, whose development is critically dependent upon the transcription factor Foxp3, have provided many clues as to the molecular mechanisms these cells employ to control immune responses and establish immune tolerance. Through these studies, G protein-coupled receptor 83 (GPR83) was found to be expressed at high levels in Treg-cell populations. However, its function remained unclear. Recently, it has been suggested that GPR83 is involved in the induction of Foxp3 expression in the peripheral nonregulatory Foxp3- CD4 T cells. To examine a role for GPR83 in Treg-cell biology, we generated and characterized GPR83-deficient mice. We have shown that GPR83 abolition does not result in measurable pathology or changes in the numbers or function of Foxp3+ Treg cells. Furthermore, while in vitro analysis suggested a potential involvement of GPR83 in transforming growth factor beta-dependent Foxp3 induction, there was no difference in the ability of nonregulatory GPR83-deficient and nondeficient Foxp3- T cells to acquire Foxp3 expression in vivo. Collectively, our results demonstrate that GPR83 is dispensable for Treg-cell development and function.

Mouse TCRalphabeta+CD8alphaalpha intraepithelial lymphocytes express genes that down-regulate their antigen reactivity and suppress immune responses

Mouse small intestine intraepithelial lymphocytes (IEL) that express alphabetaTCR and CD8alphaalpha homodimers are an enigmatic T cell subset, as their specificity and in vivo function remain to be defined. To gain insight into the nature of these cells, we performed global gene expression profiling using microarray analysis combined with real-time quantitative PCR and flow cytometry. Using these methods, TCRalphabeta(+)CD8alphaalpha IEL were compared with their TCRalphabeta(+)CD8beta(+) and TCRgammadelta(+) counterparts. Interestingly, TCRalphabeta(+)CD8alphaalpha IEL were found to preferentially express genes that would be expected to down-modulate their reactivity. They have a unique expression pattern of members of the Ly49 family of NK receptors and tend to express inhibitory receptors, along with some activating receptors. The signaling machinery of both TCRalphabeta(+)CD8alphaalpha and TCRgammadelta(+) IEL is constructed differently than other IEL and peripheral T cells, as evidenced by their low-level expression of the linker for activation of T cells and high expression of the non-T cell activation linker, which suppresses T cell activation. The TCRalphabeta(+)CD8alphaalpha IEL subset also has increased expression of genes that could be involved in immune regulation, including TGF-beta(3) and lymphocyte activation gene-3. Collectively, these data underscore the fact that, while TCRalphabeta(+)CD8alphaalpha IEL resemble TCRgammadelta(+) IEL, they are a unique population of cells with regulated Ag reactivity that could have regulatory function.

Foxp3-dependent programme of regulatory T-cell differentiation

Regulatory CD4+ T cells (Tr cells), the development of which is critically dependent on X-linked transcription factor Foxp3 (forkhead box P3), prevent self-destructive immune responses. Despite its important role, molecular and functional features conferred by Foxp3 to Tr precursor cells remain unknown. It has been suggested that Foxp3 expression is required for both survival of Tr precursors as well as their inability to produce interleukin (IL)-2 and independently proliferate after T-cell-receptor engagement, raising the possibility that such 'anergy' and Tr suppressive capacity are intimately linked. Here we show, by dissociating Foxp3-dependent features from those induced by the signals preceding and promoting its expression in mice, that the latter signals include several functional and transcriptional hallmarks of Tr cells. Although its function is required for Tr cell suppressor activity, Foxp3 to a large extent amplifies and fixes pre-established molecular features of Tr cells, including anergy and dependence on paracrine IL-2. Furthermore, Foxp3 solidifies Tr cell lineage stability through modification of cell surface and signalling molecules, resulting in adaptation to the signals required to induce and maintain Tr cells. This adaptation includes Foxp3-dependent repression of cyclic nucleotide phosphodiesterase 3B, affecting genes responsible for Tr cell homeostasis.

Regulatory T cells prevent catastrophic autoimmunity throughout the lifespan of mice

Mice lacking the transcription factor Foxp3 (Foxp3(-)) lack regulatory T (T(reg)) cells and develop fatal autoimmune pathology. In Foxp3(-) mice, many activated effector T cells express self-reactive T cell receptors that are expressed in T(reg) cells in wild-type mice. Thus, in wild-type mice, most self-reactive thymocytes escaping negative selection are diverted into the T(reg) lineage, and whether T(reg) cells are critical in self-tolerance in wild-type mice remains unknown. Here, acute in vivo ablation of T(reg) cells demonstrated a vital function for T(reg) cells in neonatal and adult mice. We suggest that self-reactive T cells are continuously suppressed by T(reg) cells and that when suppression is relieved, self-reactive T cells become activated and facilitate accelerated maturation of dendritic cells.

Cardiac output--pulse contour analysis vs. pulmonary artery thermodilution

BACKGROUND

The aims of this study were to determine the agreement between pulmonary artery thermodilution (PA-TD), transpulmonary thermodilution (TP-TD) and the pulse contour method, and to test the ability of the pulse contour method to track changes in cardiac output.

METHODS

Cardiac output was determined twice before cardiac surgery with both PA-TD and TP-TD. The precision (two standard deviations of the difference between repeated measurements) and agreement of the two methods were calculated. Post-operatively, cardiac output was determined with the PA-TD and pulse contour methods, and the bias and limits of agreement were again calculated. Finally, in patients with heart rates below 60 beats/min or a cardiac index of less than 2.5 l/min/m2, atrial pacing was started and the haemodynamic consequences were monitored with the PA-TD and pulse contour methods.

RESULTS

Twenty-five patients were included. The precisions of PA-TD and TP-TD were 0.41 l/min [95% confidence interval (CI), +/- 0.07] and 0.48 l/min (95% CI, +/- 0.08), respectively. The bias and limits of agreement between PA-TD and TP-TD were - 0.46 l/min (95% CI, +/- 0.11) and +/- 1.10 l/min (95% CI, +/- 0.19), respectively. Post-operatively, the bias and limits of agreement between the PA-TD and pulse contour methods were 0.07 l/min and +/- 2.20 l/min, respectively. The changes in cardiac output with atrial pacing were in the same direction and of the same magnitude in 15 of the 16 patients.

CONCLUSION

The precision of cardiac output measurements with PA-TD and TP-TD was very similar. The transpulmonary method, however, overestimated the cardiac output by 0.46 l/min. Post-operatively, cardiac output measurements with the PA-TD and pulse contour methods did not agree, but the pulse contour method reliably tracked pacing-induced changes in cardiac output.

A function for interleukin 2 in Foxp3-expressing regulatory T cells

Regulatory T cells (T(reg) cells) expressing the forkhead family transcription factor Foxp3 are critical mediators of dominant immune tolerance to self. Most T(reg) cells constitutively express the high-affinity interleukin 2 (IL-2) receptor alpha-chain (CD25); however, the precise function of IL-2 in T(reg) cell biology has remained controversial. To directly assess the effect of IL-2 signaling on T(reg) cell development and function, we analyzed mice containing the Foxp3(gfp) knock-in allele that were genetically deficient in either IL-2 (Il2(-/-)) or CD25 (Il2ra(-/-)). We found that IL-2 signaling was dispensable for the induction of Foxp3 expression in thymocytes from these mice, which indicated that IL-2 signaling does not have a nonredundant function in the development of T(reg) cells. Unexpectedly, Il2(-/-) and Il2ra(-/-) T(reg) cells were fully able to suppress T cell proliferation in vitro. In contrast, Foxp3 was not expressed in thymocytes or peripheral T cells from Il2rg(-/-) mice. Gene expression analysis showed that IL-2 signaling was required for maintenance of the expression of genes involved in the regulation of cell growth and metabolism. Thus, IL-2 signaling seems to be critically required for maintaining the homeostasis and competitive fitness of T(reg) cells in vivo.

Regulatory T cell lineage specification by the forkhead transcription factor foxp3

Regulatory T cell-mediated dominant tolerance has been demonstrated to play an important role in the prevention of autoimmunity. Here, we present data arguing that the forkhead transcription factor Foxp3 acts as the regulatory T cell lineage specification factor and mediator of the genetic mechanism of dominant tolerance. We show that expression of Foxp3 is highly restricted to the subset alphabeta of T cells and, irrespective of CD25 expression, correlates with suppressor activity. Induction of Foxp3 expression in nonregulatory T cells does not occur during pathogen-driven immune responses, and Foxp3 deficiency does not impact the functional responses of nonregulatory T cells. Furthermore, T cell-specific ablation of Foxp3 is sufficient to induce the identical early onset lymphoproliferative syndrome observed in Foxp3-deficient mice. Analysis of Foxp3 expression during thymic development suggests that this mechanism is not hard-wired but is dependent on TCR/MHC ligand interactions.

Precision of bolus thermodilution cardiac output measurements in patients with atrial fibrillation

BACKGROUND

The precision of bolus thermodilution cardiac output measurements in patients with atrial fibrillation (AF) has not previously been determined. A priori we suspected that the precision would be lower in patients with AF than in patients with sinus rhythm (SR). Consequently, we also determined if the precision could be improved by injecting the thermal indicator into the right ventricle instead of the right atrium.

METHODS

Cardiac output was determined as the average result of four injections of 10 ml of iced saline. Replicate measurements were performed with thermal indicator injections into the right atrium and ventricle. The coefficients of variation and the precisions were calculated.

RESULTS

In the 25 patients with AF, mean cardiac output was 3.96 l min(-1) (range 2.4-7.4), the coefficient of variation 0.073 (95% CI +/- 0.011), and the precision 0.38 l min(-1) (95% CI +/- 0.14) with injection into the right atrium. In the 25 patients with SR, mean cardiac output was 4.73 l min(-1) (range 2.4-7.3), the coefficient of variation 0.047(95% CI +/- 0.006), and the precision 0.38 l min(-1) (95% CI +/- 0.14). In both groups, an agreement analysis demonstrated that the injection of indicator into the right ventricle resulted in a significantly higher cardiac output [AF+0.25 (95% CI +/- 0.15) l min(-1), SR+0.29 ( +/- 0.20) l min(-1)].

CONCLUSION

The coefficient of variation for cardiac output determinations is 55% higher in patients with AF. Two measurements, separated by time or intervention, must differ by 15% in AF patients and 9% in SR patients before one can be 95% confident that a real change has taken place.

Diversification of exogenous genes in vivo in Neurospora

We have adapted the meiotic recombination hotspot cog of Neurospora crassa for shuffling exogenous DNA, providing a means of generating novel genes in situ from sequences introduced into chromosomes. Genes to be diversified are inserted between the his-3 locus and cog. Diversification crosses are heterozygous both for alleles of the exogenous DNA and for auxotrophic alleles of his-3. Progeny selected for ability to grow without histidine supplementation are enriched for exchange events within the exogenous DNA. Exchange events initiated by cog can propagate past DNA sequences mismatched for more than 370 bp and complete exchanges in patches of matched sequence as short as 24 bp, parameters that make the system suited for use in the directed evolution of genes for protein engineering. Here we demonstrate the system by shuffling human immunoglobulin kappa chain genes and also endoglucanase genes derived from different species of fungi.

Recombination at his-3 in Neurospora declines exponentially with distance from the initiator, cog

By deletion of 1.8 kb of sequence between cog(L) and his-3 and replacement with sequences of different lengths, we have generated a set of Neurospora strains in which the distance between cog(L) and the site at which recombination is selected varies from 1.7 to nearly 6 kb. Each of the manipulated strains includes cog(L), a highly active recombination hotspot, and rec-2, thus allowing high-frequency recombination. In addition, each is a his-3 mutant, either K26 or K480. The frequency of His(+) recombinants in progeny of these crosses is inversely proportional to the distance between his-3 and cog. Specifically, there is a linear relationship between log(10) (recombination frequency) and the distance in base pairs, indicating that as distance decreases, the rate of interallelic recombination increases exponentially. An exponential relationship between distance separating markers and the chance of co-conversion has been found in both Drosophila and fission yeast, indicating that the extension of recombination events may be a stochastic process in most organisms. On the basis of these and additional data presented in this article, we conclude that recombination is initiated at cog(L) in >17% of meioses, that most conversion tracts are very short, and that few extend >14 kb.

Thermodilution cardiac output. Cold vs room temperature injectate and the importance of measuring the injectate temperature in the right atrium

BACKGROUND

The feasibility of thermodilution cardiac output measurements with the more convenient room temperature thermal indicator instead of cold injectates has been repeatedly investigated. However, the issue has not been addressed with the appropriate statistical approach advocated by Altman and Bland. Furthermore, we wished to determine if the incorporation of a second thermistor in the thermodilution catheter, to measure the temperature of the thermal indicator where it is delivered into the right atrium/superior caval vein, would result in more precise cardiac output measurements.

METHODS

Fifty patients were randomized to receive a single or dual thermistor pulmonary artery thermodilution catheter. Cardiac output was calculated as the average of four injections of 10 ml of isotonic saline. Precision (2 x SD of differences in replicate measurements) for the two catheters and injectate temperatures, and bias and limits of agreement between measurements, with cold and room temperature injectates, were determined.

RESULTS

Precision was (0 degrees C) 0.42 l/min and (20 degrees C) 0.90 l/min, and bias and limits of agreement -0.83 l/min and -1.93-0.27 l/min for the single thermistor catheter. For the dual thermistor system precision was (0 degrees C) 0.34 l/min and (20 degrees C) 0.58 l/min. Bias and limits of agreement were -0.03 l/min and -0.61-0.55 l/min.

CONCLUSION

The second thermistor is redundant if cold injectates are used. If one wishes to use room temperature injectates the single thermistor system is inadequate. A dual thermistor catheter is, on the other hand, acceptable.

Recombination events in Neurospora crassa may cross a translocation breakpoint by a template-switching mechanism

To assist investigation of the effect of sequence heterology on recombination in Neurospora crassa, we inserted the Herpes simplex thymidine kinase gene (TK) as an unselected marker on linkage group I, giving a gene order of Cen-his-3-TK-cog-lpl. We show here that in crosses heterozygous for TK, conversion of a his-3 allele on one homolog is accompanied by transfer of the heterologous sequence between cog and his-3 from the other homolog, indicating that recombination is initiated centromere-distal of TK. We have identified a 10-nucleotide motif in the cog region that, although unlikely to be sufficient for hotspot activity, is required for high-frequency recombination and, because conversion of silent sequence markers declines on either side, may be the recombination initiation site. Additionally, we have mapped conversion tracts in His(+) progeny of a translocation heterozygote, in which the translocation breakpoint separates cog from the 5' end of his-3. We present molecular evidence of recombination on both sides of the breakpoint. Because recombination is initiated close to cog and the event must therefore cross the translocation breakpoint, we suggest that template switching occurs in some recombination events, with repair synthesis alternating between use of the homolog and the initiating chromatid as template.

Effects of glutamine on the immune system: influence of muscular exercise and HIV infection

Glutamine increased the proliferative response and the lymphokine-activated killer cell activity of blood mononuclear cells isolated from normal healthy subjects (n = 6) in a dose-dependent manner, with optimum at 0.3-1.0 mM. The relative fraction of CD3+, CD4+, CD8+, CD14+, CD16+, and CD19+ cells was not changed by glutamine at a concentration of 0.6 mM, except in the phytohemagglutinin-stimulated proliferation experiment where the fraction of CD4+, and therefore CD3+ cells, increased. The natural killer cell activity was not influenced by glutamine. Human immunodeficiency virus (HIV)-seropositive subjects (n = 8) who performed concentric bicycle exercise for 1 h at 75% of maximal O2 consumption had an overall lower phytohemagglutinin-stimulated proliferative response, compared with the HIV-seronegative control group (n = 7). The proliferation during exercise was lower in both the HIV-seropositive and the HIV-seronegative group. Addition of glutamine in vitro did not normalize the lower proliferation in the HIV-seropositive group or the attenuated proliferation seen during exercise in both groups.

Effect of methylprednisolone on endotoxemia and complement activation during cardiac surgery

The influence of high doses of methylprednisolone on complement activation and endotoxin concentration was investigated in two groups of eight patients undergoing coronary artery bypass grafting. Group 1 received methylprednisolone, 30 mg/kg, at the induction of anesthesia; group 2 served as the control group. The endotoxin concentrations increased significantly in both groups at the start of cardiopulmonary bypass. During cardiopulmonary bypass, the endotoxin concentrations were significantly higher in the steroid group compared with the control group (p less than 0.01). After completion of surgery, the endotoxin concentrations declined to almost zero within seven days in both groups. Complement activation was significantly reduced in the steroid-treated group during cardiopulmonary bypass compared with the control group (P less than 0.01). The clinical outcome after the first postoperative week was the same in the two groups. It appears that high-dose steroids can reduce complement activation during cardiopulmonary bypass, although the clearance of endotoxins may also be reduced.

Endotoxemia and enhanced generation of oxygen radicals by neutrophils from patients undergoing cardiopulmonary bypass

Plasma endotoxin concentrations and oxidative burst response of peripheral blood polymorphonuclear leukocytes were examined in 12 patients undergoing coronary artery bypass. The measurements were made just before the operation, 5 minutes after removal of the aortic crossclamp, and 24 hours after the operation. Endotoxin was quantitated by a combination of a sensitive Limulus amebocyte lysate assay and rocket immunoelectrophoresis measuring picogram amounts of endotoxin. Peripheral blood neutrophils were purified by a two-step dextran sedimentation and metrizoate sodium Ficoll (Lymphoprep., Nyegaard, Oslo, Norway) centrifugation. The oxidative burst response of these cells was measured for their ability to generate superoxide anion and was determined by a cytochrome c reduction assay. Preoperatively, all the plasma samples except one were free of endotoxin. The endotoxin levels reached 100 pg/ml 5 minutes after removal of the aortic crossclamp, and except in one sample they had decreased 24 hours after the operation. Studies on the generation of superoxide by neutrophils showed a decline in the response 5 minutes after removal of the aortic crossclamp and an enhancement of the response to f-Met-Leu-Phe by cells obtained from 11 of 12 patients 24 hours postoperatively. In vitro addition of bacterial lipopolysaccharide to blood from healthy individuals also enhanced the superoxide response of the neutrophils. We conclude that during cardiopulmonary bypass the circulating blood is contaminated by endotoxin and the neutrophils are primed for enhanced generation of oxygen radicals. The released oxygen radicals may be involved in the tissue damage observed in these patients.

Presence of circulating endotoxins during cardiac operations

Ten patients having coronary artery bypass grafting were intraoperatively and postoperatively analyzed for endotoxins with the Limulus amoebocyte lysate test. A new highly sensitive rocket immunoelectrophoretic assay for reading the reactions of endotoxins with Limulus amoebocyte lysate was used. Preoperatively, all blood samples from the patients had negative Limulus amoebocyte lysate tests, negative blood cultures, normal total white cell counts, and were clinically without signs of infection. Intraoperatively, a substantial amount of endotoxins were found in samples from the extracorporeal circuit, the pulmonary artery, and the cardiac suction lines, which persisted during the cardiopulmonary bypass. The endotoxin content decreased significantly (p less than 0.05) 6 hours after cardiopulmonary bypass and further decreased within the seventh postoperative day (p less than 0.01). A positive Limulus amoebocyte lysate test was also found in some of the fluids administered during the operation, that is, the cardioplegic fluids, the priming fluids for the extracorporeal circuit, the blood transfusions, and the ice for local cooling. Postoperatively, all patients had rectal temperatures below 38.5 degrees C, but no correlation was found between the magnitude of endotoxin content and the degree of fever. Only one of the patients had positive blood cultures. Despite the measured endotoxin content, no intraoperative or postoperative complications were found.

PEEP reverses nitroglycerin-induced hypoxemia following coronary artery bypass surgery

Intravenous nitroglycerin is increasingly used during and after cardiac surgery to control blood pressure and improve subendocardial and peripheral circulation. A dramatic decrease in arterial oxygenation has, however, been reported in a number of poorly controlled clinical trials. In the present investigation 16 patients were studied 2-4 h after coronary artery bypass procedures. All were treated with a continuous infusion of nitroglycerin (1 microgram X kg-1 X min-1). Utilizing an on-off-on drug design, it was clearly established that nitroglycerin depresses arterial oxygenation by increasing the pulmonary venous admixture. Three possible underlying mechanisms are discussed, but at the present time no firm conclusion can be drawn as to the nature of the changes. Eight patients were ventilated with 1 kPa (10 cmH2O) positive end-expiratory pressure (PEEP) during the nitroglycerin infusion. PEEP-ventilation reversed nitroglycerin-induced changes in arterial oxygenation and pulmonary shunting without adversely affecting hemodynamic stability.

Hemodynamic effects of alfentanil in verapamil-treated dogs

The hemodynamic effects of alfentanil were investigated in six dogs receiving verapamil 0.5 mg X kg-1 and six dogs receiving saline in equal volume. Basic measurements were done after 30 min and the dogs were then given alfentanil 160 micrograms X kg-1 with measurements at 5, 15, and 30 min. Significant increases in central venous pressure (CVP), mean pulmonary arterial pressure and pulmonary wedge pressure (PWP) were found 30 min after verapamil. After verapamil-alfentanil, increases were seen in CVP and PWP at 5 and 15 min and in PWP at 30 min. Mean arterial pressure and cardiac index were unchanged, while a decrease in heart rate was fully compensated by an increase in stroke volume. Indices of contractility were unchanged. All values were within the limits of normal hemodynamic function. We conclude that high-dose alfentanil has no adverse effects on hemodynamic parameters during calcium blockade.

Alfentanil and skeletal muscle circulation, oxygen consumption and P50

The preservation of blood flow to skeletal muscles has low priority in the intact organism. If cardiovascular function is disturbed, for example by anesthetic drugs, skeletal muscle circulation diminishes or stops. Skeletal muscle surface pH (m-pH) is a sensitive indicator of muscle cell oxygenation and a fall in m-pH therefore provides an early warning of deterioration in overall cardiovascular performance. In the present study we investigated the peripheral effects of a new short-acting fentanyl derivative, alfentanil. Twelve dogs were anesthetized with a bolus injection of alfentanil 0.16 mg . kg-1 i.v. M-pH was recorded continuously, while total body oxygen consumption, oxygen transport and P50 were calculated. No changes were found. In the second part of the study, we pretreated six of the dogs with the "calcium antagonist" verapamil 0.5 mg X kg-1, while the other six dogs served as controls. After a rechallenge dose of alfentanil, we again found the peripheral perfusion sufficient to meet the oxygen demand of the muscles. Side-effects to alfentanil were a decrease in Pao2, due to an increase in pulmonary shunting of venous blood, and an increase in PaCO2. The changes in pulmonary ventilation-perfusion relationships were, however, not of a magnitude that should cause concern when alfentanil is used in normal subjects.

Nitroglycerin for ergotism. Experimental studies in vitro and in migraine patients and treatment of an overt case

Ergotamine was used to induce arterial contraction in vitro (measurement of isometric tension in segments from 3 human temporal arteries) and in vivo (peripheral systolic blood pressure measured by strain gauge plethysmography in 5 migrainous patients). In both these models of ergotism, the directly acting vasodilator nitroglycerine (NTG) effectively relieved the ergotamine-induced arterial contractions. A case of ergotism treated successfully with NTG infusion is reported. The diagnosis was based on history and measurement of peripheral systolic blood pressure by strain gauge plethysmography. The latter technique was also used to monitor the response to treatment for 20 h. Blood levels of ergotamine during ergotism were in the therapeutic range. Possible explanations for this finding are discussed.

High-dose analgesic anesthesia with morphine or sufentanil in propranolol-treated dogs

In propranolol-pretreated dogs (2 mg . kg -1) the immediate cardiovascular effects of sufentanil (0.01 mg . kg -1) or morphine (4 mg . kg -1) were compared. Besides a 40% decrease in cardiac index (CI), sufentanil and morphine initiated quite different hemodynamic changes. Sufentanil did not significantly change mean arterial pressure (MAP), central venous pressure (CVP) and mean pulmonary artery pressure (MPAP), while the pulmonary capillary wedge pressure (PCWP) increased by 50%. After morphine, MAP declined significantly by about 65%, and significant decreases in MPAP (14%) and PCWP (33%) were also observed. Propranolol reduced heart rate by 16%, and morphine caused no further reduction in HR. A significant decrease of about 30% was seen in HR after sufentanil. Sufentanil significantly raised systemic vascular resistance index (SVRI) by 15%, whereas morphine decreased it by 32%. Pulmonary vascular resistance index (PVRI) was unchanged after sufentanil, but significantly increased after morphine. Right ventricular stroke work index (RVSWI) was unaffected by both analgesics, and morphine decreased left ventricular work index (LVSWI) significantly by 80%. Oxygen transport index declined significantly after both analgesics. Sufentanil reduced oxygen consumption by 20%, while morphine left this parameter unaffected. We conclude that the administration of high-dose sufentanil leads to a stable circulation, even when a total beta-blockade exists.

Skeletal muscle circulation during sufentanyl and morphine anesthesia in propranolol treated dogs

Sufentanyl is a new, potent, short-acting, fentanyl-like morphinomimetic. In the present study we compared the effects of high doses of sufentanyl and morphine on the peripheral circulation in beta-blocked dogs. Skeletal muscle surface pH (m-pH) was recorded continuously as an index of the microcirculation. Sufentanyl (0.01 mg/kg) had no adverse effects on the peripheral perfusion. Morphine (4 mg/kg) caused a severe and rapid fall in m-pH from 7.34 to 7.14 during the 30-min experimental period. At the same time calculated blood volume decreased by 20%. This hypovolemic deterioration of the circulation was probably caused by a histamine-mediated increase in capillary pressure and filtration of plasma from the intravascular space to the interstitial space. As sufentanyl could be safely administered to beta-blocked dogs, we recommend human studies. On the other hand, we discourage the use of high-dose morphine anesthesia until human studies have proved that the collapse of the peripheral perfusion seen in this study is species specific.

Early response in central hemodynamics to high doses of sufentanil or morphine in dogs

The hemodynamic effects of high doses of sufentanil, a newly synthetized highly potent analgesic, were investigated in dogs. This study compared the early (30 min) cardiovascular effects of sufentanil 0.01 mg . kg-1 and morphine 4 mg . kg-1. Sufentanil caused a moderate and insignificant decrease in mean arterial pressure (MAP). A 30% decrease in cardiac index (CI) was almost outbalanced by an increased systemic vascular resistance (SVRI). The lowering of CI was due to a more than 50% decrease in heart rate (HR) which was partly compensated for by a greater stroke volume index (SVI). In the first 5 min after morphine injection, MAP fell significantly to about 50 mmHg (below 50% of the control value). CI was reduced to about 50% of the control value because of significant decreases in both SVI and HR. The calculated SVRI was unchanged after morphine. Within 30 min some of the initially changed parameters had returned to control levels. Central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) increased immediately after sufentanil, but decreased after morphine. With time, both parameters returned towards control values. Peak left ventricular dP/dt decreased by about 25-50% after both analgesics. The rate-pressure products (RPP) were significantly decreased to less than one half of the control values after both analgesics. Mixed venous oxygen tension (PVO2), oxygen transport and oxygen consumption were significantly lowered in the sufentanil group, whereas immediate decreases after morphine were followed by gradual increases towards control values. We conclude that the use of high doses of sufentanil in dogs is safe. Apart from initial, transient changes, a stable cardiovascular state characterizes the high-dose sufentanil anesthesia, while morphine causes fluctuations in several hemodynamic parameters. Compared to morphine anesthesia, sufentanil anesthesia appears to be an attractive alternative which deserves further evaluation in humans.

Transcutaneous oxygen measurement during thoracic anaesthesia

The value of transcutaneous oxygen tension (tcPO2) as an oxygen parameter during uncomplicated thoracic anaesthesia was examined in ten patients anaesthetized with oxygen-nitrous oxide and enflurane or flunitrazepam/fentanyl. tcPO2 was measured with the Radiometer TCM-I monitor at 45 degrees C. Measuring interference due to the anaesthetic agents was not observed. tcPO2 was found to be lower than the arterial tension (PaO2) at any inspiratory oxygen fraction (FIO2). When the peroperative readings were related to the preoperative values, no statistically significant difference was found between PaO2 and tcPO2 at FIO2 - 0.5, 0.4 and 0.3 (P greater than 0.3). Linear regression between PaO2 and tcPO2 shows disparity in pre- and peroperative regression. tcPO2 (preoperative) = -2.2 + 1.03 X PaO2 (4 = 0.89) tcPO2 (preoperative) = +3.1 + 0.56 X PaO2 (r = 0.87). This disparity indicates a decrease in the tcPO2/PaO2 ratio with increasing PaO2. It is concluded that tcPO2 cannot substitute for PaO2, but tcPO2 and PaO2 proved to be equally useful as oxygen parameters in the examined patients. Interpretation of tcPO2 during anaesthesia, however, necessitates a preoperative measurement as reference.

Thiopentone-nitrous oxide-halothane anaesthesia and suxamethonium: pretreatment with pancuronium and gallamine

Eighty healthy adult patients randomly allocated to four groups received pancuronium 0.01, 0.015, 0.02 mg kg-1 or gallamine 0.3 mg kg-1 i.v. 3 min before induction. Just before induction of anaesthesia, the patients were examined for signs and symptoms of neuromuscular blockade. After induction of anaesthesia with thiopentone, suxamethonium 1.5 mg kg-1 was administered i.v. Five minutes later the second dose was injected. No serious arrhythmia was seen in any of the four groups following the repeated dose of suxamethonium. However, the highest dose of pancuronium (0.02 mg kg-1) caused an unacceptably high frequency of partial neuromuscular blockade.

Peripheral circulation during sufentanyl and morphine anesthesia

Sufentanyl is a newly developed potent, short-acting fentanyl-like morphinomimetic. No independent studies of the peripheral circulation during sufentanyl anesthesia are available. In the present study we compared the effects of sufentanyl and morphine on the peripheral perfusion in dogs. The effects of total beta-blockade during sufentanyl and morphine anesthesia were also evaluated. We elected to record skeletal muscle surface pH (m-pH) continuously as an index of the microcirculation and cellular fractions. Arterial and mixed venous blood gases and acid-base status were measured to determine the respiratory component of changes in m-pH. Hematocrits, plasma electrolytes and plasma proteins were analyzed in order to permit calculations of fluid-shifts between the blood and the interstitial fluid. Sufentanyl (0.01 mg/kg) had no adverse effects on the peripheral perfusion. Morphine (4 mg/kg) caused a severe and rapid fall in m-pH from 7.29 to 7.11 during the 30-min experimental period. At the same time, calculated blood volume decreased by 20%. This hypovolemic deterioration of the circulation was probably caused by a histamine-mediated increase in capillary pressure with filtration of plasma from the circulation to the interstitial fluid. Calculated systemic vascular resistance was not correlated to the quality of the peripheral perfusion. Propranolol administered during sufentanyl and morphine anesthesia did not influence the peripheral perfusion. On the basis of the present study we recommend human studies on sufentanyl, and discourage the use of high-dose morphine anesthesia.

Cardiac function during induction and early anesthesia with methoxyflurane. An evaluation using systolic time intervals and pressure time indices

In addition to the standard monitoring of heart rate and blood pressure, the Systolic Time Intervals were used to evaluate cardiac performance, and the Pressure Time Indices (tension time index = TTI; diastolic pressure time index = DPTI) were used to estimate myocardial oxygen balance. Twelve patients with known heart disease were studied during induction with thiopental, intubation, and early anesthesia with methoxyflurane. Cardiac performance diminished after thiopental; and during methoxyflurane it was reflected in increases in pre-ejection period (PEP) and the ratio PEP/LVET. Intubation resulted in a hyperactive state of the heart, as shown by maximal decreases in PEP and PEP/LVET. Myocardial oxygen balance--estimated from the supply/demand ratio (DPTI/TTI)--was impaired after thiopental. After intubation, DPTI/TTI decreased to its lowest value due to an excess of myocardial oxygen demand (TTI) over myocardial oxygen supply (DPTI), signifying a transitory underperfusion of the subendocardium. During methoxyflurane the oxygen balance was gradually restored towards control value. The Systolic Time Intervals and the Pressure Time Indices provided valuable information on cardiac function not available from standard monitoring alone.

Cardiac function and hypercarbia

In 12 patients with heart disease, hypercarbia was induced for carotid endarterectomy. Anesthesia was maintained with nitrous oxide in oxygen and methoxyflurane. In addition to intra-arterial measurements of blood pressure, cardiac output, systolic time intervals (STI), and pressure time indices (PTI) were determined in order to assess cardiovascular responses in these patients. Internal carotid stump blood pressure was measured in five patients before and after induction of hypercarbia. Mild elevation of the Paco2 level affected systolic time intervals but not heart rate and blood pressure. When Paco2 levels reached 56 to 65 torr, systolic but not diastolic blood pressure rose significantly, heart rate and cardiac output increased, while the shortening in the preejection period (PEP), left ventricular ejection time (LVET), and the decrease in the PEP/LVET ratio signified increased mechanical cardiac activity. Hypercarbia caused intense sympathetic stimulation as demonstrated by twofold to threefold increases in plasma catecholamine levels. Stump blood pressure was elevated. Cardiac oxygen demand was significantly increased, while coronary filling time was shortened, as indicated by the increase in the tension time index and shortening in the diastolic time. This signified a relative myocardial underperfusion. Thus, while hypercarbia to levels of 66 to 70 torr increased internal carotid artery stump pressure, it also caused increased cardiac mechanical activity and concomitant unfavorable balance between myocardial oxygen consumption and supply. The measurement of STI and the computation of PTI provided early detection of alterations in cardiac function.

Pulmonary function in obese patients scheduled for jejuno-ileostomy

Preoperative pulmonary parameters were evaluated in 37 extremely obese but otherwise healthy patients. They were on average 100.9% overweight. X-ray of the chest, electrocardiograms, and residual volume, vital capacity, total lung capacity, maximum breathing capacity, forced expired volume in 1 second, and related ratios were all within the normal range. The alveolar-arterial oxygen gradient and the arterial carbon dioxide tension were also within the normal range. The only abnormal finding was a substantially reduced arterial oxygen tension. It is suggested that the measurement of functional residual capacity, closing volume, and the slope of the alveolar plateau (phase III in the single breath nitrogen washout technique) might give more valuable information.

Evaluation of impedance cardiography druing anesthesia in extremely obese patients

In three anesthetized markedly obese patients, non-invasive stroke volumes (the transthoracic electrical impedance method) were compared to simultaneously obtained invasively measured stroke volumes (dye-dilution method). Close correlations were obtained (r = 0.90--0.98) between the two methods, although constant lower impedance stroke volumes were found in these patients when the values usually employed for the electrical resistivity of the blood (zeta) were used for calculation of the impedance stroke volume. No statistically significant difference (P greater than 0.10) between the two methods was found when a zeta of 175 ohm X cm was used for the calculations, or when the percentage changes in stroke volumes were analyzed. The impedance method is safe and reliable; it also permits non-invasive measurements of stroke volume during anesthesia in markedly obese patients.

Postoperative pulmonary function in obese patients after upper abdominal surgery

The pulmonary course after jejuno-ileal by-pass operation in six massively obese patients (mean weight 130.2 kg) was followed for the first 5 postoperative days by means of arterial blood gas analysis and measurements of forced vital capacity (FVC), forced expired volume in the first second (FEV1.0) and peak expiratory flow rate (PEFR). The patients were extubated in the operating room and were breathing spontaneously in the postoperative period. Pao2 and FVC reached their minimum values in the first 24 postoperative hours (respectively, 74% and 45% of their preoperative values), but were almost restored in 5 days. PEFR had at this time reached 77% of its preoperative value FEV1.0% (FEV1.0%in per cent of FVC) did not change from the pre- to the postoperative period, but remained about 70%.