Variability in indigenous Pakistani tomato lines and worldwide reference collection for Tomato Mosaic Virus (ToMV) and Tomato Yellow Leaf Curl Virus (TYLCV) infection

Local and exotic germplasm of tomato remains a major source for genetic improvement. Assessment of such lines for biotic stresses particularly viral diseases are the most important criteria for selection in Pakistan, where Tomato Yellow Leaf Curl Virus (TYLCV) and Tomato Mosaic Virus (ToMV) are the major diseases/viruses. A set of 40 accessions (including indigenous Pakistani lines and exotic germplasm from Europe, the United States, and Asia) were evaluated for their resistance/infection response to ToMV with artificial inoculation under greenhouse conditions. Infection response was quantified through disease scoring and DAS-ELISA test (for ToMV). A subset of 24 lines, was further screened for TYLCV using disease scoring and TAS-ELISA. The tested lines showed significant variability for resistance to ToMV. Only one accession (Acc-17878) was resistant to the ToMV whereas seven accessions i.e. Acc-17890, AVR-261, CLN-312, AVR-321, EUR-333, CLN-352, and CLN-362 expressed resistance to TYLCV. Correlation between phenotypic evaluation was confirmed by the ELISA results in both diseases, although both tools complemented to assess the viral infection status. In future, tomato breeding programs must consider breeding for ToMV and TYLCV resistance (using identified germplasm in our study) so as to deliver virus resistant tomato varieties.

P4670Long-term changes of exercise haemodynamics and physical capacity in chronic thromboembolic pulmonary hypertension after pulmonary thromboendarterectomy

Background

A substantial number of chronic thromboembolic pulmonary hypertension (CTEPH) patients experience dyspnoea on exertion and limited exercise capacity despite surgically successful pulmonary endarterectomy (PEA).

Purpose

We sought to prospectively evaluate resting and peak exercise haemodynamics before, 3 and 12 months after PEA in consecutive CTEPH patients and correlate it to physical functional capacity.

Methods

Twenty CTEPH patients who underwent PEA treatment were examined between December 2014 and January 2017. The patients were examined pre-operatively and 3 and 12 months post-operatively with right heart catheterisation at rest and during a maximal symptom-limited, semi-supine cardiopulmonary exercise test. Finally, the data were compared with 15 healthy controls who had previously undergone the same protocol.

Results

Twelve months after PEA, 75% of patients with severely increased pre-PEA mean pulmonary arterial pressure (mPAP) at rest had normal or mildly increased mPAP. However, mPAP reduction was less pronounced during exercise where only 45% had normal or mildly increased mPAP at 12 months. Cardiac output (CO) reserve (CO increase from rest to peak exercise) was increased (5.7±2.9 L/min) 12 months after PEA compared with pre-PEA (2.5±1.8 L/min), p<0.0001. However, 12 months after PEA, the CO reserve was only 49% of that of healthy controls, p<0.0001. Changes in cardiac output (ΔCO), calculated as the difference between CO before PEA and 12 months later, were significantly correlated with six-minute-walk-test and peak oxygen uptake (VO2), both at rest and peak exercise.

Figure 1

Conclusion

Invasive exercise haemodynamic examination in CTEPH patients demonstrates that after otherwise successful PEA surgery, more than 50% of patients have a significant increase in exercise mPAP, and the CO reserve remains compromised 12 months after PEA. Improvement in physical capacity is correlated with ΔCO.

Acknowledgement/Funding

Danish Heart Foundation, Aarhus University, Arvid Nilssons Fond, Eva & Henry Frænkels Mindefond, and Snedkermester Sophus Hustru Astrid Jacobsens Fond

Biomechanical assessment of the aortic root using novel force transducers

In recent years the use of valve sparing techniques has become more common in selected patients with aortic valve insufficiency. However, limited experimental research has been performed to document the biomechanical effect of these techniques. One experimental platform is to evaluate how the normal physiological aortic root forces are altered or re-established after the surgical intervention. Hence, the aim of this project was to develop new implantable force transducers for a biomechanical description of various aortic root repair techniques. Two novel force transducers were developed. Both transducers were manufactured using rapid prototyping and were instrumented with miniature strain gauges. Before implantation both transducers were calibrated using a dedicated setup, yielding very linear correlation between the applied load and transducer output. The developed force transducers were implanted and tested in an 80kg porcine model. In the post-cardioplegic heart, the peak annular forces varied in the range of 2-4N and the commissural forces varied from 0.4 to 0.8N with a left ventricular pressure of 111mmHg. In conclusion, the two new force transducers to measure forces in the aortic root have successfully been developed. With these new devices a novel versatile and direct force measurement system has been provided.

Antipsychotics and associated risk of out-of-hospital cardiac arrest

Antipsychotic drugs have been associated with sudden cardiac death, but differences in the risk of out-of-hospital cardiac arrest (OHCA) associated with different antipsychotic drug classes are not clear. We identified all OHCAs in Denmark (2001-2010). The risk of OHCA associated with antipsychotic drug use was evaluated by conditional logistic regression analysis in case-time-control models. In total, 2,205 (7.6%) of 28,947 OHCA patients received treatment with an antipsychotic drug at the time of the event. Overall, treatment with any antipsychotic drug was associated with OHCA (odds ratio (OR) = 1.53, 95% confidence interval (CI): 1.23-1.89), as was use with typical antipsychotics (OR = 1.66, CI: 1.27-2.17). By contrast, overall, atypical antipsychotic drug use was not (OR = 1.29, CI: 0.90-1.85). Two individual typical antipsychotic drugs, haloperidol (OR = 2.43, CI: 1.20-4.93) and levomepromazine (OR = 2.05, CI: 1.18-3.56), were associated with OHCA, as was one atypical antipsychotic drug, quetiapine (OR = 3.64, CI: 1.59-8.30).

Decreasing incidence rates of bacteremia: a 9-year population-based study

BACKGROUND

Numerous studies have shown that the incidence rate of bacteremia has been increasing over time. However, few studies have distinguished between community-acquired, healthcare-associated and nosocomial bacteremia.

METHODS

We conducted a population-based study among adults with first-time bacteremia in Funen County, Denmark, during 2000-2008 (N = 7786). We reported mean and annual incidence rates (per 100,000 person-years), overall and by place of acquisition. Trends were estimated using a Poisson regression model.

RESULTS

The overall incidence rate was 215.7, including 99.0 for community-acquired, 50.0 for healthcare-associated and 66.7 for nosocomial bacteremia. During 2000-2008, the overall incidence rate decreased by 23.3% from 254.1 to 198.8 (3.3% annually, p < .001), the incidence rate of community-acquired bacteremia decreased by 25.6% from 119.0 to 93.8 (3.7% annually, p < .001) and the incidence rate of nosocomial bacteremia decreased by 28.9% from 82.2 to 56.0 (4.2% annually, p < .001). The incidence rate of healthcare-associated bacteremia remained stable. The most common microorganisms were Escherichia coli (28.3%), Staphylococcus aureus (12.3%), coagulase-negative staphylococci (10.0%) and Streptococcus pneumoniae (9.1%). Regardless of place of acquisition, the proportion of bacteremias caused by enterococci increased (p < .05) and the proportion caused by coagulase-negative staphylococci decreased (p < .05).

CONCLUSIONS

The incidence rates of community-acquired and nosocomial bacteremia decreased substantially over time.

In Vitro System for Measuring Chordal Force Changes Following Mitral Valve Patch Repair

BACKGROUND

Attention towards optimization of mitral valve repair methods is increasing. Patch augmentation is one strategy utilized to correct functional mitral regurgitation or systolic anterior motion in complex mitral valve repairs. This article describes a system for investigating the redistribution of chordae tendineae tension as a reflection of altered stress distribution of the valve leaflet following patch augmentation.

METHODS AND MATERIALS

An in vitro test setup was constructed to hold native porcine mitral valves containing an annulus and papillary muscle positioning system. The alterations caused by patch augmentation should be visual from both the atrial and ventricular views. Ventricular pressure was regulated stepwise in a range of 0-150 mmHg. To test the system, the anterior mitral leaflet was extended by a pericardial patch sutured to the mid/basal part of the leaflet, and the chordae tendineae force was measured as the ventricular pressure was applied.

RESULTS

The system demonstrated the capacity to hold native porcine mitral valves and introducing patch repairs according to clinical practice. The porcine mitral valve test setup indicated strong correlation between the forces in the mitral valve secondary chordae tendineae and the applied transvalvular pressure (R² = 0.95).

CONCLUSION

This test setup proved the ability to obtain normal mid-systolic mitral valve function, secondary chordae force measurements, and important preservation of the visual access: Hence, obtaining the pressure-force relationship as well as identifying any shift of the secondary chordae insertion point on the anterior leaflet relative to the coaptation zone was made possible.

Abstract P4-08-08: Cross Reactivity of Clinically Validated Anti-HER2 Antibodies

Background: Human epidermal growth factor receptor (HER-) 2 belongs to the family of epidermal growth factor receptors (EGFRs) with homology to HER1, HER3 and HER4. HER2 is over-expressed in approximately 20% of invasive human breast cancers (Wolff, Hammond et al. 2007). Over-expression of HER2 is associated with a poor prognosis; however, the protein can be targeted by anti-HER2 therapy (trastuzumab, Herceptin®) (Slamon, Leyland-Jones et al. 2001). Trastuzumab therapy is offered only to patients whose tumors over-express HER2 protein and/or show amplification of the HER2 gene. Accordingly, the expression level of HER2 protein and/or amplification of the HER2 gene are determined routinely in all newly diagnosed breast cancers. Essential to this testing of HER2 expression at the protein level is the availability of specific antibody-based test systems.

Aim: The aim of the present study was to investigate the specificity of three clinically approved commercially available anti-HER2 antibodies towards members of the EGFR-family.

Methods: We studied the antibody used in the Herceptest™ (Dako), the PATHWAY® antibody (Ventana Medical Systems, Inc.) and the Oracle™ antibody (Leica Microsystems). Antibody specificity was investigated by manually performed immunohistochemistry (IHC) and in competitive ELISAs. For IHC, Chinese Hamster Ovary (CHO) cells were transiently transfected with the intracellular domain of respectively HER1, HER2, HER3 and HER4 and all three antibodies were applied to sections of formalin-fixed paraffin-embedded (FFPE) transfected cells. In ELISA, cross reactivity towards HER1 and HER4 was tested with peptides corresponding to the C-terminal part of HER1 and HER4.

Results: In IHC experiments, all three antibodies stained cells transfected with HER2. Binding of the antibodies to HER2 was confirmed bycompetitive ELISA. However, in IHC experiments the PATHWAY® and the Oracle™ antibodies also stained cells transfected with HER4. Competitive ELISAs confirmed binding of the PATHWAY® antibody to HER4, whereas binding of the Oracle™ antibody to HER4 could not be confirmed in a competitive ELISA. None of the antibodies cross reacted with HER1 and HER3 homologous to the HER2 binding site of the antibodies.

Conclusions: Two out of three clinically validated anti-HER2 antibodies were shown to cross react with HER4 in FFPE cells. As determination of HER2 over-expression and/or amplification guides therapy with trastuzumab, a valid test result by the use of specific antibodies is crucial to ensure proper personalized therapy with HER2-targeted therapy. These results warrant further investigation of anti-HER2 antibodies and of the procedures for clinical determination of HER2 protein expression. References:

Slamon DJ et al. (2001) J Med 344:783 Wolff AC et al. (2007) J Clin Oncol 25:118

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-08-08.

Fecal calprotectin: assessment of a rapid test

BACKGROUND

Calprotectin, a protein found mainly in neutrophil granulocytes, is used as an inflammatory marker, while the fecal concentration of the protein is used to detect gastrointestinal (GI) inflammation.

MATERIAL AND METHODS

Fecal calprotectin in 100 stool samples was measured by the ELISA method and by a new rapid test. Eighty-two patients had fecal calprotectin measured for clinical reasons and delivered 95 stool samples. The rest were delivered by healthy volunteers.

RESULTS

The association between the two tests was statistically significant (p<0.0001, chi(2) test). With calprotectin values <15 microg/g, the sensitivity and specificity of the new rapid test was 96 % (95 % confidence interval (CI), 87-100 %) and 70 % (CI, 55-83 %), respectively, with a negative predictive value of 94 % (CI, 81-99 %). With values >15 microg/g, the rapid test was less accurate, thus rendering results in this range difficult to interpret.

CONCLUSIONS

The new rapid test is useful as a screening test for excluding GI inflammation when the cut-off of 15 microg/g is used. With fecal calprotectin concentrations >15 microg/g, the rapid test should be supplemented by quantitative measurement.

Improved survival after an out-of-hospital cardiac arrest using new guidelines

BACKGROUND

An out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis. We hypothesized that the implementations of 2005 European Resuscitation Council resuscitation guidelines were associated with improved 30-day survival after OHCA.

METHODS

We prospectively recorded data on all patients with OHCA treated by the Mobile Emergency Care Unit of Copenhagen in two periods: 1 June 2004 until 31 August 2005 (before implementation) and 1 January 2006 until 31 March 2007 (after implementation), separated by a 4-month period in which the above-mentioned change took place.

RESULTS

We found that 30-day survival increased after the implementation from 31/372 (8.3%) to 67/419 (16%), P=0.001. ROSC at hospital admission, as well as survival to hospital discharge, were obtained in a significantly higher proportion from 23.4% to 39.1%, P<0.0001, and from 7.9% to 16.3%, P=0.0004, respectively. Treatment after implementation was confirmed as a significant predictor of better 30-day survival in a logistic regression analysis.

CONCLUSION

The implementation of new resuscitation guidelines was associated with improved 30-day survival after OHCA.

Prehospital identification of stroke--room for improvement

INTRODUCTION

Rapid recognition of stroke is important because it allows early brain imaging and management such as thrombolytic therapy. We evaluated the identification of the diagnosis acute cerebrovascular incident in a physician-based prehospital emergency medical system.

METHODS

From the Copenhagen Mobile Emergency Care Unit (MECU) register we identified patients classified as having an acute cerebrovascular incident through a 2-year period. We subsequently searched the hospital registration system and compared the consistency between the primary hospital discharge diagnosis and the MECU diagnosis made on referral. Our primary aim was to calculate the proportion of admitted patients with a hospital discharge diagnosis from the category 'acute cerebrovascular incident.'

RESULTS

In total, 583 patients were included in our study. In 25 patients, no hospital discharge diagnosis could be found. Of the remaining 558 patients, a hospital discharge diagnosis of cerebrovascular incident was made for 168 (30.1%) patients. Other cerebral disease was found in 171 (30.7%), systemic disease in 52 (9.3%), and other diagnoses in 167 (29.9%).

DISCUSSION

We found a low accuracy of the clinical diagnosis acute cerebrovascular incident in the prehospital setting with room and need for improvement in order to allow appropriate and expeditious referral for thrombolytic therapy.

Dosage dependent hormonal counter regulation to combination therapy in patients with left ventricular dysfunction

The present study attempts to assess the efficacy combination therapy for heart failure. Genuine dose-response studies on combination therapy are not available and published studies involved adding one drug on top of 'usual treatment'. Sixteen different dosage combinations of trandolapril and bumetanide was tested in a double blind, double placebo-controlled, randomized, multiple cross-over study in a 16 times six balanced incomplete Latin square design. Patients reported optimal quality of life on the sub maximal dose bumetanide. Bumetanide decreased left ventricular function and increased heart rate and plasma noradrenaline in a dose dependent manner. Doses of bumetanide of more than 0.5 mg, given twice daily significantly decreased the quality of life and increased diuresis. Weight loss was maximal on 0.5 mg bumetanide twice daily. Trandolapril significantly reduced systolic blood pressure with the maximal effect at 0.5 mg daily. Both drugs significantly increased renin concentration with a significant potentiating interaction. It was not possible to detect beneficial effects of combination therapies. The optimal dosage of Bumetanide appeared to be 0.5 mg twice daily based on its effect on quality of life and weight loss. Estimated by the reduction in systolic blood pressure the optimal dosage of Trandolapril appeared to be 0.5 mg once daily.

CONCLUSIONS

It appears that patients should be given less than the usually recommended dosages. Patients may be treated with a low dose loop diuretic, if signs of water retention are present or if symptomatic relief is desired.

Response, relapse and mucosal immune regulation after infliximab treatment in fistulating Crohn's disease

BACKGROUND

Infliximab reduces mucosal inflammation in some, but not all, patients with Crohn's disease.

AIM

To monitor clinical data and changes in mucosal cytokine levels after infliximab treatment to identify differences between responders and non-responders.

METHODS

Twenty-six patients with fistulating Crohn's disease received three infliximab infusions at weeks 0, 2 and 6. Follow-up was for 1 year and included clinical examination, colonoscopy, ano-rectal ultrasound and magnetic resonance imaging. Biopsies were taken at weeks 0, 8, 26 and 52. Cell cultures were established and analysed for tumour necrosis factor-alpha, interferon-gamma and interleukin-10 levels, and related to clinical status and fistula healing.

RESULTS

Eleven of 15 patients (73%) with active disease (Crohn's disease activity index > 150) obtained remission (Crohn's disease activity index < 150) at 8 weeks. In in vitro cell cultures, there was reduced tumour necrosis factor-alpha and interleukin-10 production at week 26, with the latter persistent throughout the study period. When the disease deteriorated or relapsed, there was increased interferon-gamma production in in vitro cell cultures. Fistula healing was associated with reduced production of interferon-gamma, tumour necrosis factor-alpha and interleukin-10.

CONCLUSIONS

Infliximab down-regulates mucosal immune activation in Crohn's disease. Monitoring of mucosal cytokine levels after infliximab treatment by whole biopsy cultures may be useful as interleukin-10, tumour necrosis factor-alpha and interferon-gamma production are different in responders and at relapse.

Identification of two nucleotide sequence sub-groups within Potato mop-top virus

To evaluate the variation of Potato mop-top pomovirus from potato fields, 21 isolates were collected from different Danish locations. Reverse transcription-polymerase chain reaction-restriction fragment length polymorphism (RT-PCR-RFLP) of regions of RNA2 was performed for all 21 isolates resulting in the establishment of two sub-groups of isolates. The nucleotide sequence of a region encoding part of the 'readthrough protein' of RNA2 was compared for 9 of these isolates. This sequence analysis confirmed the RT-PCR-RFLP grouping. The isolates were tested for symptom expression in indicator plants and grouped according to symptom development. No correlation between grouping based on symptom development and genotype was observed.

Functional monitoring of anthracycline cardiotoxicity: a prospective, blinded, long-term observational study of outcome in 120 patients

BACKGROUND

With increasing doses the highly tumoricidal anthracycline drugs cause heart damage. Based on empirical drug limitations about 10-15% of patients will develop congestive heart failure (CHF) with a mortality of -50% within 2 years on digitalo-diuretic therapy alone. To avoid CHF there is a consensus recommendation that cardiac function should be monitored in close connection with anthracycline administration. As no prospective studies in a larger series have been performed, these recommendations are based on retrospective data on small numbers of patients.

PATIENTS AND METHODS

In a prospective, blinded observational study 120 patients with advanced breast cancer were followed before, during, and a median 3 years after treatment with epirubicin. They had 604 serial radionuclide measurements of left ventricular ejection fraction (LVEF) that were stored without calculations except in patients who developed a well-defined CHF.

RESULTS

Anthracycline cardiotoxicity was closely correlated with the cumulative dose, with a great variability in individual susceptibility and a dramatic increase with advancing age. With a delayed onset of 3 months or more, epirubicin induced a threatening, slowly progressive deterioration of cardiac function continuing years after treatment. An actuarial estimation of 59% of the patients experienced a 25% relative reduction in LVEF 3 years after 850-1000 mg/m2 of epirubicin and 20% had deteriorated into a CHF. The patients did not spontaneously regain cardiac function whereas continued therapy with a circadian angiotensin-converting enzyme inhibitor for more than 3 months caused a remarkably potent and long-lasting recovery.

CONCLUSIONS

Due to the displaced cardiotoxic manifestation, functional monitoring in close connection with anthracycline administration appears to be a poorly effective method while later monitoring is essential. Current monitoring recommendations should therefore be revised.

[St Jude's bi-leaflet aortic valve prosthesis throughout two decades. Quality profile and risk factors]

INTRODUCTION

The St Jude standard aortic bi-leaflet disc valve is still the most widespread. With almost 20 years of follow-up, the present material may describe the quality profile of the valve and the relevant risk factors throughout the remainder of most patients' lives.

MATERIAL AND METHODS

A 100% complete follow-up was conducted of 694 adult patients who had an aortic valve replacement with the St Jude valve during 1980-1993. The Cox regression analysis was used to identify independent risk factors.

RESULTS

Survival was 79%, 58%, 39%, and 37% at 5, 10, 15, and 18 years, respectively. Only 12% of the deaths (0.60%/patient-year) were valve-related with a 15-year freedom of 91%. Embolism (1.18%/patient-year) and anticoagulant-related bleeding (2.24%/patient-year) were the dominant complications with 15-year freedoms of 80% and 72%. Valve thrombosis was noted in two patients (0.04%/patient-year) who were off anticoagulation. Mechanical failure was not observed. Endocarditis (0.42%/patient-year) had a 15-year freedom of 92% compared with 72% and 54%, respectively, for major valve (2.33%/patient-year) and all valve-related complications together (4.33%/patient-year) and 96% for aortic valve reoperation (0.36%/patient-year). Age of the patient and heart-related variables were identified as independent risk factors for mortality and valve-related complications.

CONCLUSION

With a follow-up of almost two decades showing a low incidence of valve-related deaths, acceptable thrombogenicity, and absence of mechanical failure, the St Jude bi-leaflet aortic disc valve sets the standard for contemporary mechanical valves.

Florid vascular proliferation of the colon related to intussusception and mucosal prolapse: potential diagnostic confusion with angiosarcoma

With the exception of angiodysplasia, vascular abnormalities of the intestines are unusual. We describe a florid benign vascular proliferation of the colon in five adult patients, three of whom presented with idiopathic intussusception. In all cases, the proliferation was sufficiently exuberant to raise the possibility of angiosarcoma as a diagnostic consideration. The group included 2 males and 3 females with a median age of 43 years. Two patients were HIV positive. Four patients presented with a colonic mass; other symptoms at presentation included abdominal pain, diarrhea, bleeding, and bowel obstruction. In all cases, a florid lobular proliferation of small vascular channels lined by plump endothelial cells extended from the submucosa through the entire thickness of the bowel wall. The endothelial cells showed minimal nuclear atypia, and mitotic figures were infrequent. The overlying mucosa showed ulceration with ischemic-type changes, and had features of mucosal prolapse. A possible underlying arteriovenous malformation was identified in two cases. All patients were alive and well at last follow-up (interval, 6 months to 5 years). The presence of intussusception or mucosal prolapse in all of the cases suggests repeated mechanical forces applied to the bowel wall as a possible etiologic factor. The role of HIV infection in the pathogenesis of these lesions remains to be determined.

Edge-to-edge mitral repair: tension on the approximating suture and leaflet deformation during acute ischemic mitral regurgitation in the ovine heart

BACKGROUND

Edge-to-edge approximation of the mitral valve leaflets (Alfieri procedure) is a novel surgical treatment for patients with ischemic mitral regurgitation (IMR). Long-term durability may be limited if abnormal mitral leaflet stresses result from this procedure. The aim of the current study was to measure Alfieri stitch tension (F(A)) and to explore its geometric determinants in an ovine model of acute IMR as a reflection of the mitral leaflet stresses imposed by the procedure.

METHODS AND RESULTS

Eight sheep were studied immediately after surgical placement of (1) a force transducer interposed between sutures approximating the central leaflet edges and (2) radiopaque markers around the mitral annulus and leaflet edges. Computer-aided analysis of videofluorograms was used to obtained 3D marker coordinates. Simultaneous measurements of F(A), septal-lateral annular dimension (L(S-L)), leaflet edge separation (L(SEP)), anterior (L(AL)) and posterior (L(PL)) leaflet length, and hemodynamic variables were obtained at baseline (CTL) and during acute IMR (circumflex artery occlusion). F(A) was significantly elevated throughout the cardiac cycle during IMR compared with CTL, with maximum F(A) in diastole (0.26+/-0.05 versus 0.46+/-0.08 N, CTL versus IMR; P<0.05). Multivariable analysis revealed L(S-L) as the single independent predictor of maximum F(A) (P<0.001). Positive linear correlations were shown between values of F(A) and L(AL) and L(PL) (dependent variables).

CONCLUSIONS

These experimental data demonstrate higher F(A) during IMR and cyclic changes in F(A) closely paralleling changes in L(S-L), eg, being greatest in diastole when the annulus is largest. Increased F(A) during IMR is probably indicative of successful therapeutic intent, but higher diastolic leaflet stresses resulting from persistent or progressive mitral annular dilatation may adversely affect repair durability. This indirectly implies that concomitant mitral ring annuloplasty should be added to the Alfieri repair.

Influence of anterior mitral leaflet second-order chordae on leaflet dynamics and valve competence

BACKGROUND

Chordal transposition is used in mitral valve repair, yet the effects of second-order chord transection on valve function have not been extensively studied. We evaluated leaflet coaptation, three-dimensional anterior mitral valve leaflet shape, and valve competence after cutting anterior second-order chordae.

METHODS

In 8 sheep radiopaque markers were affixed to the left ventricle, mitral annulus, and leaflets. Animals were studied immediately with biplane videofluoroscopy and echocardiography before (Control) and after (Cut2) severing two anterior second-order "strut" chordae. Leaflet coaptation was assessed as separation between leaflet edge markers in the midleaflet and near each commissure (anterior commissure, posterior commissure). Anterior leaflet geometry was determined 100 milliseconds after end-diastole from three-dimensional coordinates of 13 markers.

RESULTS

Anterior leaflet geometry changed only slightly after chordal transection without inducing mitral regurgitation. Leaflet coaptation times were 79+/-17 and 87+/-22 milliseconds at the anterior commissure; 72+/-21, 72+/-19 milliseconds at midleaflet, and 71+/-12 and 75+/-8 milliseconds at the posterior commissure (p = NS) for Control and Cut2, respectively.

CONCLUSIONS

Cutting anterior second-order chordae did not cause delayed leaflet coaptation, alter leaflet shape, or create mitral regurgitation. These data indicate that transposition of second-order anterior chordae ("strut" chordae) is not deleterious to anterior leaflet motion per se.

Limited ischemic necrosis despite prolonged basilar artery occlusion treated with local thrombolysis: A clinicopathologic study

Based on published case series, intra-arterial thrombolysis for basilar artery occlusion reduces mortality and improves outcome even when performed after considerable delays. In contrast, the current use of intravenous thrombolysis is limited to a 3-hour time window. The longer time window for intervention in patients with basilar artery occlusion may vary based on individual clinical features, such as collateral circulation and the site of the occlusion. Clinicopathologic evidence is presented from a patient with a distal basilar artery occlusion treated with local thrombolysis who later expired from a myocardial infarction complicated by cardiac tamponade. Autopsy showed infarction limited to the right pons despite symptom duration of over 72 hours and directly observed neurologic deficits for 27 hours.

Analysis of the triple gene block and coat protein sequences of two strains of Kalanchoë latent carlavirus

A region of the Kalanchoë latent carlavirus (KLV) genome, containing the coding capacity for the triple gene block and the coat protein, was cloned and sequenced for two isolates, the one infecting Chenopodium quinoa systemically whereas the other infects C. quinoa locally. The sequence confirmed the classification of KLV as a carlavirus. There was the highest identity in the amino acid sequences to the carlaviruses potato rough dwarf virus, lily latent virus, lily symptomless virus, blueberry scorch virus and potato virus S. The aminoacid sequences of proteins of the two KLV isolates had an identity between 86% and 91%.

First Record of Beet necrotic yellow vein virus in Denmark

Beet necrotic yellow vein virus (BNYVV) causes rhizomania in beets. BNYVV is widespread in Europe and can be divided into an A and B group based on reverse transcription-polymerase chain reaction (RT-PCR) restriction fragment length polymorphism (RFLP) analysis (1). The vector of BNYVV, Polymyxa betae, is widespread in Denmark. However, surveys for BNYVV have regularly been carried out in Denmark since 1985, but it has not been detected until now. In the autumn of 2000, attention was drawn to a sugar beet field in the southeastern part of Denmark containing plants with unusually low sugar content. Typical BNYVV symptoms of bearded roots were observed on all plants sampled in the field. Root samples of 12 plants all tested positive for the presence of BNYVV by ELISA using antiserum from Adgen, Loewe, and Aschersleben, respectively. Immunosorbent electron microscopy with antiserum to BNYVV coat protein revealed decorated rod-shaped particles of lengths typical for BNYVV. Pulverized infected root tissue was used to mechanically inoculate Chenopodium quinoa and resulted in formation of few local chlorotic lesions. RNA was extracted from symptomatic C. quinoa and subjected to RT-PCR analysis using two primer sets specific for RNA 2 of BNYVV (1) and bands of the expected sizes were observed with both. The nucleotide sequence of a part of the PCR products corresponding to the N-terminus of the coat protein was determined and showed 99.5% identity to sequences derived from A group isolates (1). Finally, a bait-plant test was carried out, where sugar beet seeds were sown in 20 soil samples collected from different locations within the infested field. After 8 weeks of growth, all samples tested positive for the presence of BNYVV by ELISA, indicating that the entire field is infested and that viruliferous P. betae must have been present in several years. To our knowledge, this is the first record of BNYVV in Denmark. Reference: (1) M. Kruse et al. J. Gen. Virol. 75:1835, 1994.

Edge-to-edge mitral repair: gradients and three-dimensional annular dynamics in vivo during inotropic stimulation

OBJECTIVE

The edge-to-edge (Alfieri) mitral repair technique appears to be clinically promising, but the potential for functional mitral stenosis, especially with exercise, remains a concern. We used the myocardial marker method combined with Doppler echocardiography to evaluate mitral annular (MA) three-dimensional (3-D) dynamics and transvalvular gradients after leaflet approximation before and during dobutamine infusion.

METHODS

Eight adult sheep underwent implantation of eight myocardial markers around the MA and nine in the left ventricle. Mitral leaflet edges were approximated at the valve center and micromanometers were placed in the left ventricle and atrium. The animals were studied with biplane videofluoroscopy to determine 3-D marker coordinates for computation of precise 3-D MA area and left ventricular (LV) volume. Epicardial Doppler echocardiography measured peak and mean diastolic mitral valve gradients at baseline and during dobutamine infusion (10 microg/kg per min).

RESULTS

During dobutamine stimulation, left ventricular dP/dt increased from 1776+/-712 to 3390+/-618 mmHg/s (P=0.002), and cardiac output (CO) increased from 2.7+/-1.1 to 5.1+/-1.2 l/min (P=0.009). Mitral annular area (MAA) at end-diastole (ED) fell from 8.6+/-1.4 to 7.0+/-1.8 cm(2) (P=0.001) with inotropic stimulation, but only a modest increase was observed in mean (1.4+/-0.4 vs. 2.4+/-1.0 mmHg, P=0.046) and peak (2.7+/-0.8 vs. 4.9+/-2.5 mmHg, P=0.03) diastolic mitral valve gradients. MAA changed dynamically throughout the cardiac cycle, reflecting normal physiology, but the magnitude of MAA change was augmented during inotropic stimulation (18+/-5% and 27+/-4% for control and dobutamine, respectively; P=0.004).

CONCLUSION

Dobutamine increased CO by 89% and decreased ED annular area by 19% after edge-to-edge repair, yet only a small increase in valve gradient occurred. Marker analysis showed enhanced dynamic motion of the mitral annulus. Thus, the edge-to-edge mitral valve repair was not associated with substantial transvalvular obstruction during high flow conditions and did not perturb normal MA 3-D dynamics in normal ovine hearts.

Standard aortic St. Jude valve at 18 years: performance profile and determinants of outcome

BACKGROUND

The standard St. Jude disc valve has been in use for 20 years and remains the dominant mechanical valve of today. With nearly 19 years of follow-up, the present large series could indicate the performance profile and its determinants in the very long term.

METHODS

A detailed follow-up was performed to a maximum of 18.6 years in 694 patients aged 15 to 83 years who undervent aortic valve replacement (AVR) with the standard St. Jude valve during 1980 to 1993. The Cox regression analysis was used to identify independent determinants of outcome in the aortic stenosis (n = 490) and regurgitation (n = 204) groups.

RESULTS

Overall survival was 58%, 39%, and 37% at 10, 15, and 18 years, respectively. Only 12% of deaths (0.60%/ patient-year) were related to the valve with a 15-year freedom of 91%. Embolism (1.18%/patient-year) and anticoagulant-related bleeding (2.24%/patient-year) were the dominant complications with 10-year/15-year freedoms of 90%/80% and 85%/72%, respectively. Only 24% of bleeding events were classified as major. Valve thrombosis occurred in 2 patients (0.04%/patient-year): 1 did not receive vitamin K antagonist treatment and International Normalized Ratio was below target level in the other. There were no mechanical failures. Endocarditis (0.42%/patient-year) and paravalvular leak (0.42%/ patient-year) occurred with 15-year freedoms of 92% and 96%, respectively, with a relation between the latter (but not the former) and preoperative endocarditis in the regurgitation group. Freedom from serious complications (2.33%/patient-year) and all complications joined (4.33%/ patient-year) were 72% and 54%, respectively, at 15 years with a 96% freedom from redo AVR (0.36%/patient-year). Age- and heart-related variables were independent risk factors for mortality, thromboembolism, bleeding, serious complications, and all complications joined. Small valve (19 and 21 mm) adversely affected serious and all complications in the regurgitation group.

CONCLUSIONS

With a follow-up approaching 2 decades and exhibiting a low rate of valve-related deaths, acceptable low thrombogenicity, and absence of mechanical failure, the standard aortic St. Jude disc valve sets the standard for contemporary mechanical valves.

Transperitoneal transport in diabetic and non-diabetic patients on peritoneal dialysis

To investigate differences in the transport characteristics of the peritoneal membrane between diabetic and non-diabetic patients on chronic peritoneal dialysis, a study was conducted in 21 non-diabetic and 18 diabetic patients. Transperitoneal transport of small solutes was evaluated in terms of the mass transfer area coefficients (urea, creatinine and glucose), ultra-filtration sieving coefficients (urea and creatinine) and by peritoneal equilibration test results. The capacity of the peritoneal membrane to transport macromolecules was evaluated by albumin mass transfer rates and clearances of albumin. Transperitoneal water transport was evaluated by the ultra-filtration properties and the lymphatic flow rates. Finally, the whole-body capillary permeability was estimated by measuring the unidirectional flux of albumin across the capillary wall, i.e. the transcapillary escape rate of 125I-labelled human albumin. Despite a significantly increased transcapillary escape rate of albumin in the diabetic patients, no differences in peritoneal membrane characteristics could be demonstrated between diabetic and non-diabetic patients on peritoneal dialysis.

First Report of Soilborne Rye Mosaic Virus in Rye in Denmark

Soilborne wheat mosaic furovirus (SBWMV)-like particles were detected in rye (Secale cereale) grown in sandy soil in West Zealand during spring 1999. Infected plants showed yellow leaf mosaic and light stunting. Electron microscopy of negatively stained crude sap preparations revealed rigid rod-shaped particles with two average lengths, 296 and 162 nm; average diameter was 23 nm. Sap-inoculation to Chenopodium quinoa and C. amaranticolor produced local leaf lesions when grown at 17°C but none when grown at 22 to 25°C. All the features agree with the description of SBWMV (1). Immunosorbent electronmicroscopy with polyclonal antiserum produced by W. Huth to furovirus-like particles isolated from rye in Germany gave a distinct decoration to particles. Light microscopy of roots cleared with 10% KOH and stained with a 0.5% solution of trypan blue in lactoglycerol revealed resting spores with a morphology and size similar to Polymyxa graminis, a furovirus vector. This is the first record of a furovirus on cereals in Denmark. The complete nucleotide sequence of the isolate was analyzed and compared with data on isolates from wheat. Sequence identity was only 74%. Therefore, the isolate was designated as soilborne rye mosaic virus. SBRMV has been recorded previously in rye and triticale in several regions of Germany (2). References: (1) M. K. Brakke. 1971. CMI/AAB Descr. Plant Viruses No. 77. (2) W. Huth. Nachrichtenbl. Dtsch. Pflanzenschutzdienstes 50:163, 1998.

Performance profile of the Starr-Edwards aortic cloth covered valve, track valve, and silastic ball valve

OBJECTIVE

The Starr-Edwards aortic ball valve has passed 30 years of clinical follow-up. A detailed account of the long-term performance from a large series could thus give valuable guidance in managing patients who are still alive, depict the total remaining life-span after aortic valve replacement (AVR) for the average patient, and set a record yet to be matched by modern disc valves.

METHODS

A detailed follow-up to a maximum of 31.1 years was performed for 717 patients who underwent their first AVR during 1965-1993 with a Starr-Edwards silastic ball valve (N = 355), a cloth covered valve (N = 164) or a track valve (N = 198) with a total of 7254 patient-years at risk.

RESULTS

Patients who received a silastic ball valve were older (average 60 vs. 58 years), had more endocarditis (9%) and more secondary kidney failure (24%) preoperatively than the other patients. The three valve types did not differ as regards long-term survival or freedom from complications and only 15% of late deaths were related to the valve. For the silastic ball valve cumulative freedoms at 10 and 25 years were 59 and 20% from all deaths (crude survival), 85 and 80% from thromboembolism, 87 and 70% from bleeding, 98 and 94% from endocarditis, 96 and 95% from redo AVR and 68 and 51% from all valve related complications joined. There were no instances of structural failure apart from wear of the cloth covering the cage struts of the cloth covered valves. Incidences of haemolysis (0.10%/patient-year) and valve thrombosis (0.06%/patient-year) were low for the silastic ball valve. Analysis of relative survival for the silastic ball valve indicated excess mortality relative to a matched background population only during 1st and 13th postoperative year. Apart from heart related factors and age, independent incremental risk factors for mortality and the various complications included, not valve type, but valve size index (valve size divided by body surface area) < or = 13 mm/m2.

CONCLUSIONS

The Starr-Edwards aortic ball valves, not least the currently available silastic ball valve, are durable through the remaining life time of the patients and able to secure near normal age and sex specific survival provided valve and patient size mismatch is avoided.

Papillary muscle misalignment causes multiple mitral regurgitant jets: an ambiguous mechanism for functional mitral regurgitation

BACKGROUND AND AIMS OF THE STUDY

The study aim was to test the hypothesis that asymmetric alignment (misalignment) of the papillary muscles is sufficient to cause incomplete mitral leaflet coaptation and functional mitral regurgitation (MR).

METHODS

Different spatial relationships between the papillary muscles and the mitral annulus were investigated in isolated porcine mitral valves in vitro to assess the impact on mitral valve competence. The systolic occlusional leaflet area (OLA) needed to cover the mitral orifice and the anterolateral (ACOM) and posteromedial (PCOM) commissural portion (OLA(ACOM), OLA(PCOM)) were assessed by 2D echocardiography to quantitate incomplete mitral leaflet coaptation. The regurgitant fraction (RF) and MR jet location were assessed by a flow meter and color Doppler ultrasound.

RESULTS

Posterolateral dislocation of the posteromedial papillary muscle impaired mitral leaflet coaptation at the corresponding half-portion of the mitral orifice (OLA(PCOM): 351-397 mm2 versus 296 mm2 (normal); p < 0.001) and modified the contralateral part (OLA(ACOM): 354-387 mm2 versus 304 mm2 (normal); p <0.001). The mitral leaflet coaptation line moved in apical and posterior directions, creating a commissural MR orifice at the PCOM side. At the ACOM side, anterior leaflet prolapse and restricted posterior leaflet mobility created an additional commissural regurgitant jet (RF = 0.11-0.13). Symmetrical papillary muscle misalignment restricted mitral leaflet mobility on both sides of the orifice in a synergistic manner (OLA(PCOM): 416-459 mm2 and OLA(ACOM): 427-489 mm2; both p <0.001 versus normal). The central MR jet orifice, which extended towards both commissures, caused more significant MR (RF = 0.15-0.26).

CONCLUSIONS

Papillary muscle misalignment caused mitral regurgitant jet ambiguity with an anterior MR jet location following posteromedial papillary muscle displacement. These findings may improve understanding of the relation between myocardial lesion and mitral regurgitant jet location and thereby facilitate rational strategies for valvular interventions.

In vivo electroporation of skeletal muscle: threshold, efficacy and relation to electric field distribution

In vivo electroporation is increasingly being used to deliver small molecules as well as DNA to tissues. The aim of this study was to quantitatively investigate in vivo electroporation of skeletal muscle, and to determine the threshold for permeabilization. We designed a quantitative method to study in vivo electroporation, by measuring uptake of (51)Cr-EDTA. As electrode configuration influences electric field (E-field) distribution, we developed a method to calculate this. Electroporation of mouse muscle tissue was investigated using either external plate electrodes or internal needle electrodes placed 4 mm apart, and eight pulses of 99 micros duration at a frequency of 1 Hz. The applied voltage to electrode distance ratio was varied from 0 to 2.0 kV/cm. We found that: (1) the threshold for permeabilization of skeletal muscle tissue using short duration pulses was at an applied voltage to electrode distance ratio of 0.53 kV/cm (+/-0.03 kV/cm), corresponding to an E-field of 0.45 kV/cm; (2) there were two phases in the uptake of (51)Cr-EDTA, the first indicating increasing permeabilization and the second indicating beginning irreversible membrane damage; and (3) the calculated E-field distribution was more homogeneous for plate than for needle electrodes, which was reflected in the experimental results.

Assessment of patients with metastatic transitional cell carcinoma of the urinary tract

PURPOSE

We propose an appropriate assessment of patients with disseminated transitional cell carcinoma of the urothelial tract, and investigate the pattern of metastases relative to pathological features and primary tumor treatment.

MATERIALS AND METHODS

A total of 156 consecutive patients with recurrent locally advanced (nonresectable, radioresistant) and/or metastatic transitional cell carcinoma of the urothelial tract were evaluated with blood tests, chest x-ray, bone scintigraphy, bone marrow biopsy, and abdominal and brain computerized tomography.

RESULTS

Distant metastases were evident in 86% of the patients, with lymph nodes and bones being the most frequent sites. Bone metastases were mostly in the pelvis or lower spine and were asymptomatic in 19% of patients. Bone marrow metastases were noted in 14% of these patients. However, most of them also had radiological bone metastases and bone marrow biopsy is not recommended for routine evaluation. Approximately 2% of patients had brain metastases without symptoms at recurrence. Elevated lactate dehydrogenase was predictive of disseminated disease. Patients receiving radical radiotherapy as primary treatment had an increased rate of recurrent locally advanced disease but the same frequency of distant metastases compared to those undergoing cystectomy. Primary tumor features did not relate to the pattern of metastases.

CONCLUSIONS

We recommend chest x-ray, whole abdominal computerized tomography and routine blood tests, including lactate dehydrogenase, for patients with recurrent locally advanced or metastatic disease. Skeletal symptoms should be examined radiologically, while asymptomatic patients with recurrence in sites other than bone should be evaluated with bone scintigraphy.

Comparison of transarterial and multiple nerve stimulation techniques for axillary block using a high dose of mepivacaine with adrenaline

BACKGROUND

High-dose transarterial (TA) technique results in high effectiveness of the axillary block. The technique is fast and simple, but does not produce a satisfactory success rate when using the manufacturer's recommended dose of mepivacaine. The multiple nerve stimulation (MNS) technique requires more time and experience. This double-blind study compared effectiveness, safety and the time used to obtain an effective analgesia in 101 patients, having an axillary block by either TA or MNS techniques.

METHODS

Mepivacaine with adrenaline (MEPA), 850 mg, was used for the initial block. Five millilitres of 1% solution was injected subcutaneously. In the TA group, 20 mL of 2% solution was injected deep to, and 20 mL superficial to the axillary artery. In the MNS group, four terminal motor nerves were electrolocated in the axilla, and injected with 10 mL each. Analgesia was assessed every 10 min and, when needed, supplemented after 30 min. The block was effective when analgesia was present in all sensory nerve areas distal to the elbow.

RESULTS

The MNS group required median 11 min for block performance compared with 8 min for the TA group (P < 0.001). Latency of the initial block was shorter and the frequency of supplemental analgesia lower in the MNS group (median 10 min and 6%) than in the TA group (30 min and 36%, respectively), P < 0.001. All incomplete blocks were successfully supplemented. However, the total time to obtain an effective block was shorter in the MNS group (23 min) than in the TA group (37 min), P < 0.001. Two patients in each group had signs and symptoms of systemic toxicity, the most serious being atrial fibrillation and temporary loss of consciousness in a cardiovascularly medicated patient. The local adverse effects (intravascular injections and haematomas) were fewer in the MNS group, P < 0.001.

CONCLUSION

The MNS technique of axillary block by four injections of 10 mL of 2% MEPA produces faster and more extensive block than the TA technique by two injections of 20 mL. Therefore, the MNS technique requires fewer supplementary blocks and results in faster patient readiness for surgery. However, high doses of MEPA may result in dangerous systemic toxic reactions.

Extracellular and intracellular killing in neutrophil granulocytes of Staphylococcus aureus with rifampicin in combination with dicloxacillin or fusidic acid

The effect of rifampicin in combination with dicloxacillin or fusidic acid on the extracellular and intracellular killing of Staphylococcus aureus in human neutrophil granulocytes in the presence of serum was studied. At the extracellular level rifampicin significantly reduced the bactericidal activity of dicloxacillin, but had an indifferent effect on the activity of fusidic acid. The combination of rifampicin with dicloxacillin or fusidic acid led to intracellular killing no different from that produced by rifampicin alone. However, owing to the high intracellular activity of rifampicin, the intracellular killing by the drug combinations was greater than that by dicloxacillin or fusidic acid alone.

Chordal force distribution determines systolic mitral leaflet configuration and severity of functional mitral regurgitation

OBJECTIVES

The purpose of this study was to investigate the impact of the chordae tendineae force distribution on systolic mitral leaflet geometry and mitral valve competence in vitro.

BACKGROUND

Functional mitral regurgitation is caused by changes in several elements of the valve apparatus. Interaction among these have to comply with the chordal force distribution defined by the chordal coapting forces (F(c)) created by the transmitral pressure difference, which close the leaflets and the chordal tethering forces (FT) pulling the leaflets apart.

METHODS

Porcine mitral valves (n = 5) were mounted in a left ventricular model where leading edge chordal forces measured by dedicated miniature force transducers were controlled by changing left ventricular pressure and papillary muscle position. Chordae geometry and occlusional leaflet area (OLA) needed to cover the leaflet orifice for a given leaflet configuration were determined by two-dimensional echo and reconstructed three-dimensionally. Occlusional leaflet area was used as expression for incomplete leaflet coaptation. Regurgitant fraction (RF) was measured with an electromagnetic flowmeter.

RESULTS

Mixed procedure statistics revealed a linear correlation between the sum of the chordal net forces, sigma[Fc - FT]S, and OLA with regression coefficient (minimum - maximum) beta = -115 to -65 [mm2/N]; p < 0.001 and RF (beta = -0.06 to -0.01 [%/N]; p < 0.001). Increasing FT by papillary muscle malalignment restricted leaflet mobility, resulting in a tented leaflet configuration due to an apical and posterior shift of the coaptation line. Anterior leaflet coapting forces increased due to mitral leaflet remodeling, which generated a nonuniform regurgitant orifice area.

CONCLUSIONS

Altered chordal force distribution caused functional mitral regurgitation based on tented leaflet configuration as observed clinically.

Latissimus dorsi cardiomyoplasty: a chronic experimental porcine model. Feasibility study of cardiomyoplasty in Danish Landrace pigs and Göttingen minipigs

Cardiomyoplasty is an experimental treatment for end-stage heart failure. We hypothesized that the porcine latissimus dorsi muscle (LDM) in an experimental porcine model is a suitable surrogate for a clinically relevant evaluation of this concept. Fourteen Danish Landrace (DL) pigs and six Göttingen minipigs (GM) were studied. The LDM was evaluated immediately after surgical dissection and in various phases: phase 1 (n = 4)--outcome of a partial vascular isolation (vascular delay), 2 to 3 weeks prior to heart wrapping in DL pigs; phase 2 (n = 6)--long-term flap survival of nonstimulated LDM cardiomyoplasty in DL pigs; phase 3 (n = 6)--outcome of nonstimulated cardiomyoplasty in GM; phase 4--one DL pig had dynamic cardiomyoplasty performed and was subjected to low-intensity LDM stimulation for 8 months. Isolation of the LDM of DL pigs and GM as a pedicled graft had no acute deleterious impact on the global blood supply. In phase 1a, partial vascular isolation and in situ recovery of the LDM resulted in a muscle encapsulated in fibrotic tissue, which hampered a later heart wrap. In phase 1b, a less extensive dissection diminished fibrosis and allowed subsequent wrapping. In phase 2, after 6 weeks of nonstimulated LDM cardiomyoplasty, the LDM of DL pigs was viable, with excellent heart-muscle integration. In phase 3, the same procedure applied in GM yielded the same result as that in DL pigs, but with a higher success rate owing to the learning phase.

The effect of dicloxacillin and fusidic acid on the extracellular and intracellular killing of Staphylococcus aureus

The effect of dicloxacillin and fusidic acid used alone and in combination on the extracellular and intracellular killing of four isolates of Staphylococcus aureus in the presence of serum was studied. At the extracellular level, dicloxacillin (8 mg/L) had a bactericidal effect on all four isolates, whereas fusidic acid (64 mg/L) had a bacteriostatic effect on two isolates and no effect on the two other isolates. Fusidic acid significantly inhibited the extracellular bactericidal effect of dicloxacillin on two isolates. Intracellular killing was measured in human neutrophil granulocytes. Dicloxacillin (8 mg/L) significantly increased the intracellular killing of all four isolates, while fusidic acid (64 mg/L) significantly increased the intracellular killing of three isolates, but the killing was significantly lower than that of dicloxacillin. When the antibiotics were combined the intracellular killing of three of the isolates was significantly lower than that of dicloxacillin alone. The viability of the granulocytes and their ability to produce superoxide anion were not affected by the antibiotics. In conclusion, we found that the increased intracellular killing of S. aureus by dicloxacillin was inhibited by fusidic acid.

Renal haemodynamics, sodium and water reabsorption during continuous intravenous infusion of recombinant interleukin-2

1. Renal haemodynamics, lithium and sodium clearance were measured in 14 patients treated with recombinant interleukin-2 for metastatic renal cell carcinoma. 2. Patients were studied before and after 72 h of continuous intravenous infusion of recombinant interleukin-2 (18x10(6) i.u..24 h-1.m-2) and 48 h post therapy. Cardiac output was measured by impedance cardiography. Effective renal plasma flow and glomerular filtration rate were determined by the renal clearances of 131I-hippuran and 99mTc-diethylenetriaminepenta-acetic acid (DTPA) respectively. Renal clearance of lithium (CLi) was used as an index of proximal tubular outflow. 3. Treatment caused a transient decrease in mean arterial blood pressure and systemic vascular resistance, but cardiac output remained unchanged. Renal blood flow decreased and renal vascular resistance increased during and after treatment. Sodium clearance decreased from 1.10 (0.63/1.19) ml/min to 0.17 (0.18/0.32) ml/min (P=0.003). Glomerular filtration rate remained unchanged, whereas the median CLi decreased from 26 (17/32) ml/min to 17 (10/21) ml/min (P=0.008). Calculated absolute proximal reabsorption rate of water increased from 63 (40/69) ml/min to 71 (47/82) ml/min (P=0.04). The urinary excretion rate of thromboxane B2 and the ratio between excretion rates of thromboxane B2 and 6-keto-prostaglandin-F1alpha increased by 98% (P=0.022) and 175% (P=0.022) respectively. 4. The study suggests a specific recombinant interleukin-2-induced renal vasoconstrictor effect. Changes in renal prostaglandin synthesis may contribute to the decrease in renal blood flow. The lithium clearance data suggest that an increased proximal tubular reabsorption rate may contribute to the decreased sodium clearance during recombinant interleukin-2 treatment.

The effect of quinolones on the intracellular killing of Staphylococcus aureus in neutrophil granulocytes

The effect of ciprofloxacin, lomefloxacin, fleroxacin and ofloxacin on the intracellular killing of Staphylococcus aureus in human neutrophil granulocytes was studied. Each drug was tested in concentrations of 0.25, 1, 4, 16 and 64 times the MIC and the intracellular killing was measured for up to 5 h of incubation. All four quinolones increased the intracellular killing in a concentration- and time-dependent manner. When compared at concentrations of 4 x MIC, ofloxacin increased the killing significantly more than the other quinolones. All four quinolones increased the killing significantly more than the beta-lactam dicloxacillin. All five antibiotics increased the killing significantly relative to the control without antibiotics. None of the antibiotics affected the viability of the granulocytes or their ability to generate superoxide anion. In conclusion, the quinolones increased the intracellular killing of S. aureus in neutrophil granulocytes.

[Angiotensin-converting enzyme inhibitor in the treatment of epirubicin-induced dilated cardiomyopathy]

Anthracycline chemotherapy of cancer can cause severe, frequently fatal congestive heart failure (CHF), the first line treatment for which is diuretics and digoxin. We have studied the use of an ACE-inhibitor added as a third agent. Of 85 patients evaluable for cardiotoxicity after treatment with a median of 1000 mg/m2 of epirubicin for metastatic breast cancer, nine developed CHF at 1.5 to 13 months after therapy. Left ventricular ejection fraction decreased from normal to 18 to 35%. All patients received digitalo-diuretic therapy and after a transient clinical relief enalapril or ramipril increasing from 1.25 mg orally daily to 10-15 mg after 4-6 weeks. Eight of the nine patients deteriorated while on digitalo-diuretic therapy. Within three months of starting the ACE-inhibitor in these patients, LVEF increased to normal or near normal. Only one patient died in heart failure. Follow-up ranged from 11-42 months (median 26) and survival in the nine patients was similar to that of those who did not develop CHF. We suggest that treatment of anthracycline-induced CHF with an ACE-inhibitor should start within one to two weeks after digitalo-diuretic therapy regardless of the severity of symptoms rather than waiting for clinical deterioration.

Medial temporal lobe heterotopia as a cause of increased hippocampal and amygdaloid MRI volumes

Magnetic resonance imaging (MRI)-based volumetric measurements of the hippocampus and amygdala are useful in detecting hippocampal and amygdaloid sclerosis in patients with temporal lobe epilepsy. In these pathological entities, volumetric MRI analysis shows the epileptogenic structures to be atrophic when compared to the normal, nonepileptogenic side. Described are 2 patients with increased hippocampal and amygdaloid volumes on the side of seizure onset due to medial temporal lobe heteroto pias. Care must be taken in the interpretation of volumetric MRI data to make certain that asymmetries in hippocampal and amygdaloid measurements are due to atrophy and sclerosis of the abnormal side and not to increased tissue such as heterotopic gray matter.

Autotransfused shed mediastinal blood has normal erythrocyte survival

BACKGROUND

Autotransfusion of shed mediastinal blood may reduce the need for homologous blood transfusions in cardiac surgery. In an earlier study we have shown that the red blood cells (RBCs) of shed mediastinal blood have a normal membrane stability (osmotic fragility) compared with circulating RBCs after coronary artery bypass grafting and better than stored RBCs. This indicates that RBCs in shed mediastinal blood are not damaged further during salvage. It remains to be determined how autotransfusion affects the survival of RBCs from shed mediastinal blood.

METHODS

We performed a prospective, randomized, and controlled study involving 26 patients having elective, uncomplicated coronary artery bypass grafting. Dual-isotope labeling technique (chromium 51 and technetium 99m) was used to investigate the 24-hour survival of RBCs from shed mediastinal blood and RBCs from circulating blood, and to estimate the mean survival time of RBCs.

RESULTS

There was no significant difference between the 24-hour survival of shed mediastinal RBCs and circulating RBCs. The estimated mean cell lifespan was 20.5 days (range, 11.6 to 29.0 days) for shed mediastinal RBCs and 22.7 days (range, 14.4 to 36.2 days) for circulating RBCs.

CONCLUSIONS

The survival of RBCs from shed mediastinal blood after autotransfusion is comparable with the survival of RBCs in the patients' circulating blood.

Pre- and afterload reduction in chronic mitral regurgitation: a double-blind randomized placebo-controlled trial of the acute and 2 weeks' effect of nifedipine or isosorbide dinitrate treatment on left ventricular function and the severity of mitral regurgitation

1. The acute effect and effect of 14 days' treatment with isosorbide dinitrate (ISDN) and nifedipine (NIF) was evaluated by radionuclide cardiography in patients with chronic mitral regurgitation and sinus rhythm. 2. In 23 patients with clinically stable disease blood pressure was lowered by 15% and left ventricular volume was reduced by 16-20% after 20 mg sublingual ISDN causing combined pre- and afterload reduction. Afterload reduction alone induced by 10 mg NIF resulted in an acute 9% decrease in left ventricular endsystolic volume, whereas forward stroke volume increased by 30%, and regurgitation fraction tended to decrease. No haemodynamic effects could be detected after 14 days' treatment with 20 mg ISDN orally twice daily (preload reduction), whereas 20 mg NIF twice daily (afterload reduction) caused an increase in forward stroke volume (18%) and a decrease in both regurgitant volume (20%) and regurgitation fraction (22%) without affecting blood pressure or heart rate. 3. ISDN and NIF have beneficial acute haemodynamic effects in patients with chronic mitral regurgitation probably due to their pre- and afterload reducing properties. The reduction in regurgitation induced by NIF appears to be sustained after 14 days therapy.

Treatment with angiotensin-converting-enzyme inhibitor for epirubicin-induced dilated cardiomyopathy

BACKGROUND

Anthracycline chemotherapy in cancer can cause severe, frequently fatal congestive heart failure (CHF), the first-line treatment for which is diuretics and digoxin. We have studied the use of an angiotensin-converting-enzyme (ACE) inhibitor added as a third agent.

METHODS

In an observational study in hospital and as outpatients, 92 patients with advanced breast cancer were treated with epirubicin at a cumulative dose of 360 to 1000 mg/m2 (median 1000). Of 85 evaluable, nine developed life-threatening CHF at 1.5 to 13 months after ending epirubicin. Left ventricular ejection fraction (LVEF) decreased from normal to 18 to 35%. All received frusemide and digoxin, and then, after transient clinical relief, enalapril or ramipril (initially 1.25 mg orally daily, increasing to 10-15 mg after 4-6 weeks).

FINDINGS

Eight of the nine patients deteriorated while on digoxin/diuretic. Within 3 months of starting the ACE inhibitor in these patients, LVEF had increased to normal or near normal. Only one patient died in heart failure. Follow-up ranged from 11 to 42 months (median 26). The ACE inhibitor was well-tolerated, with no first-dose hypotension, except for one patient who discontinued treatment after 6 months because of persistent cough. Two others discontinued treatment with their ACE inhibitor after 22 and 28 months because they felt well. Survival in the nine patients was similar to that of those who did not develop CHF.

INTERPRETATION

Our experience suggests that treatment of anthracycline-induced CHF with an ACE inhibitor should start soon after clinical improvement on digoxin/diuretic regardless of the severity of symptoms rather than waiting for clinical deterioration.