A dust-enshrouded tidal disruption event with a resolved radio jet in a galaxy merger

Tidal disruption events (TDEs) are transient flares produced when a star is ripped apart by the gravitational field of a supermassive black hole (SMBH). We have observed a transient source in the western nucleus of the merging galaxy pair Arp 299 that radiated >1.5 × 10⁵² erg at infrared and radio wavelengths but was not luminous at optical or x-ray wavelengths. We interpret this as a TDE with much of its emission reradiated at infrared wavelengths by dust. Efficient reprocessing by dense gas and dust may explain the difference between theoretical predictions and observed luminosities of TDEs. The radio observations resolve an expanding and decelerating jet, probing the jet formation and evolution around a SMBH.

Intestinal microbiome as a risk factor for urinary tract infections in children

As urinary tract infection (UTI) pathogens originate from the gut, we hypothesized that the gut environment reflected by intestinal microbiome influences the risk of UTI. Our prospective case-control study compared the intestinal microbiomes of 37 children with a febrile UTI with those of 69 healthy children. We sequenced the regions of the bacterial 16S rRNA gene and used the LefSe algorithm to calculate the size of the linear discriminant analysis (LDA) effect. We measured fecal lactoferrin and iron concentrations and quantitative PCR for Escherichia coli. At the phylum level, there were no significant differences. At the genus level, Enterobacter was more abundant in UTI patients with an LDA score > 3 (log 10), while Peptostreptococcaceae were more abundant in healthy subjects with an LDA score > 3 (log 10). In total, 20 OTUs with significantly different abundances were observed. Previous use of antimicrobials did not associate with intestinal microbiome. The relative abundance of E. coli was 1.9% in UTI patients and 0.5% in controls (95% CI of the difference-0.8 to 3.6%). The mean concentration of E.coli in quantitative PCR was 0.14 ng/μl in the patients and 0.08 ng/μl in the controls (95% CI of the difference-0.04 to 0.16). Fecal iron and lactoferrin concentrations were similar between the groups. At the family and genus level, we noted several differences in the intestinal microbiome between children with UTI and healthy children, which may imply that the gut environment is linked with the risk of UTI in children.

Bridged Epipolythiodiketopiperazines from Penicillium raciborskii, an Endophytic Fungus of Rhododendron tomentosum Harmaja

Three new epithiodiketopiperazine natural products [outovirin A (1), outovirin B (2), and outovirin C (3)] resembling the antifungal natural product gliovirin have been identified in extracts of Penicillium raciborskii, an endophytic fungus isolated from Rhododendron tomentosum. The compounds are unusual for their class in that they possess sulfide bridges between α- and β-carbons rather than the typical α-α bridging. To our knowledge, outovirin A represents the first reported naturally produced epimonothiodiketopiperazine, and antifungal outovirin C is the first reported trisulfide gliovirin-like compound. This report describes the identification and structural elucidation of the compounds by LC-MS/MS and NMR.

Tandem mass spectrometric analysis of S- and N-linked glutathione conjugates of pulegone and menthofuran and identification of P450 enzymes mediating their formation

RATIONALE

Menthofuran is a hepatotoxin and a major metabolite of pulegone, a monoterpene found in the essential oils of many mint species. It is bioactivated by cytochrome P450 (CYP) enzymes to reactive metabolites, which may further react with glutathione to form S-linked and N-linked conjugates. The tandem mass spectrometric (MS/MS) fragmentation pathways of rarely observed N-linked conjugates, and the differences to fragmentation of S-linked conjugates, have not been reported in the literature previously, although this information is essential to enable comprehensive MS/MS-based screening methods covering the both types of conjugates.

METHODS

(R)-(+)-Pulegone, (S)-(-)-pulegone, and menthofuran were incubated with a human liver S9 fraction with glutathione (GSH) as the trapping agent. Conjugates were searched with ultra-performance liquid chromatography (UPLC)/orbitrap MS and their MS/MS spectra were measured both in the negative and positive ionization polarities. Menthofuran was also incubated with recombinant human CYP enzymes and GSH to elucidate the CYPs responsible for the formation of the reactive metabolites.

RESULTS

Four GSH conjugates of menthofuran were detected and identified as S- and N-linked conjugates based on MS/MS spectra. N-linked conjugates lacked the characteristic fragments of S-linked conjugates and commonly produced fragments that retained parts of glutamic acid. CYP1A2, 2B6 and 3A4 were observed to produce more GSH conjugates than other CYP isoforms.

CONLUSIONS

Furans can form reactive aldehydes that react in Schiff-base fashion with the free glutamyl-amine of GSH to form N-linked conjugates that have distinct MS/MS spectra from S-linked adducts. This should be taken into account when setting up LC/MS/MS-based detection of glutathione conjugates to screen for reactive metabolites, at least for compounds with a furan moiety. Neutral loss scanning of 178.0412 Da and 290.0573 Da in the positive ionization mode, or neutral loss scanning of 256.0695 Da and 290.0573 Da and precursor ion scanning of m/z 143.0462 in the negative ionization mode, is recommended. Copyright © 2016 John Wiley & Sons, Ltd.

Unfavourable short-term outcomes of a poly-L/D-lactide scaffold for thumb trapeziometacarpal arthroplasty

The bioabsorbable poly-L-D-lactide joint scaffold arthroplasty is a recent attempt in the reconstruction of small joints in rheumatoid patients. In this study, we analysed the 1-year clinical, functional and radiologic results of partial trapeziectomy with the poly-L-D-lactide (96/4) joint scaffold in 23 patients with isolated trapeziometacarpal osteoarthritis. The results showed that the procedure provided pain relief and improvement in overall function according to the Quick Disabilities of the Arm, Shoulder and Hand score in most patients. However, radiographs demonstrated a high frequency of osteolysis around the implant. Seven patients developed clinically manifested foreign-body reactions 6 months to 1 year after surgery. The reason for the unexpected tissue reactions may relate to excessive mechanical cyclic loading of the implant. The outcomes of this implant in our patients have not been sufficiently beneficial and we have discontinued use of this implant in isolated trapeziometacarpal osteoarthritis.

Toxicity of Carboxylic Acid-Containing Drugs: The Role of Acyl Migration and CoA Conjugation Investigated

Many carboxylic acid-containing drugs are associated with idiosyncratic drug toxicity (IDT), which may be caused by reactive acyl glucuronide metabolites. The rate of acyl migration has been earlier suggested as a predictor of acyl glucuronide reactivity. Additionally, acyl Coenzyme A (CoA) conjugates are known to be reactive. Here, 13 drugs with a carboxylic acid moiety were incubated with human liver microsomes to produce acyl glucuronide conjugates for the determination of acyl glucuronide half-lives by acyl migration and with HepaRG cells to monitor the formation of acyl CoA conjugates, their further conjugate metabolites, and trans-acylation products with glutathione. Additionally, in vitro cytotoxicity and mitochondrial toxicity experiments were performed with HepaRG cells to compare the predictability of toxicity. Clearly, longer acyl glucuronide half-lives were observed for safe drugs compared to drugs that can cause IDT. Correlation between half-lives and toxicity classification increased when "relative half-lives," taking into account the formation of isomeric AG-forms due to acyl migration and eliminating the effect of hydrolysis, were used instead of plain disappearance of the initial 1-O-β-AG-form. Correlation was improved further when a daily dose of the drug was taken into account. CoA and related conjugates were detected primarily for the drugs that have the capability to cause IDT, although some exceptions to this were observed. Cytotoxicity and mitochondrial toxicity did not correlate to drug safety. On the basis of the results, the short relative half-life of the acyl glucuronide (high acyl migration rate), high daily dose and detection of acyl CoA conjugates, or further metabolites derived from acyl CoA together seem to indicate that carboxylic acid-containing drugs have a higher probability to cause drug-induced liver injury (DILI).

Glutathione trapping of reactive drug metabolites produced by biomimetic metalloporphyrin catalysts

RATIONALE

Metalloporphyrins can be useful in the production of drug metabolites, as they enable easier production of oxidative metabolites usually produced by the cytochrome P450 enzymes. Our aim was to test metalloporphyrin-based biomimetic oxidation (BMO) methods for production and S-glutathione trapping of reactive drug metabolites in addition to phase I metabolites.

METHODS

Clozapine, ticlopidine and citalopram were selected as model compounds. These were incubated with the BMO assay and the incubations were analyzed with high-resolution liquid chromatography/mass spectrometry (LC/MS) and tandem mass spectrometry (LC/MS/MS). Additionally, incubations with human liver S9 fraction were performed to compare the results with the BMO assay.

RESULTS

Six glutathione conjugates were identified for clozapine from the S9 incubation, while the BMO assay produced four of these. Four out of the five phase I metabolites produced by S9 were detected using the BMO assay. For ticlopidine, four glutathione conjugates were detected from the S9 incubation, but none of these were observed using the BMO assay. Eight of the nine phase I metabolites produced by S9 incubation were detected in the BMO assay. As expected, no glutathione conjugates were detected for citalopram, and the same three phase I metabolites were detected in both S9 and BMO incubations.

CONLUSIONS

Differences in formation of GSH-trapped reactive metabolites by BMO assay between clozapine and ticlopidine are probably due to different reactive intermediates and reaction mechanisms. The reactive intermediate of clozapine, the nitrenium ion was generated, but the reactive intermediates of ticlopidine, S-oxide and epoxide, were not detected from the incubations. However, the results show that for selected cases the use of biomimetic assays can be used to produce high amounts of S-glutathione conjugates identical to those from liver subfraction incubations, on a scale that is relevant for purification and subsequent identification by NMR spectroscopy; which is often difficult using incubations with liver subfractions.

Metabolism of α-thujone in human hepatic preparations in vitro

This study aims to characterize the metabolism of α-thujone in human liver preparations in vitro and to identify the role of cytochrome P450 (CYP) and possibly other enzymes catalyzing α-thujone biotransformations. With a liquid chromatography-mass spectrometry (LC-MS) method developed for measuring α-thujone and four potential metabolites, it was demonstrated that human liver microsomes produced two major (7- and 4-hydroxy-thujone) and two minor (2-hydroxy-thujone and carvacrol) metabolites. Glutathione and cysteine conjugates were detected in human liver homogenates, but not quantified. No glucuronide or sulphate conjugates were detected. Major hydroxylations accounted for more than 90% of the primary microsomal metabolism of α-thujone. Screening of α-thujone metabolism with CYP recombinant enzymes indicated that CYP2A6 was principally responsible for the major 7- and 4-hydroxylation reactions, although CYP3A4 and CYP2B6 participated to a lesser extent and CYP3A4 and CYP2B6 catalyzed minor 2-hydroxylation. Based on the intrinsic efficiencies of different recombinant CYP enzymes and average abundances of these enzymes in human liver microsomes, CYP2A6 was calculated to be the most active enzyme in human liver microsomes, responsible for 70-80% of the metabolism on average. Inhibition screening indicated that α-thujone inhibited both CYP2A6 and CYP2B6, with 50% inhibitory concentration values of 15.4 and 17.5 µM, respectively.

Identification of phenolic compounds from lingonberry (Vaccinium vitis-idaea L.), bilberry (Vaccinium myrtillus L.) and hybrid bilberry (Vaccinium x intermedium Ruthe L.) leaves

Phenolic compounds from leaves of lingonberry (Vaccinium vitis-idaea L.), bilberry (Vaccinium myrtillus L.), and the natural hybrid of bilberry and lingonberry (Vaccinium x intermedium Ruthe L., hybrid bilberry) were identified using LC/TOF-MS and LC/MS/MS after extraction from the plant material in methanol in an ultrasonicator. The phenolic profiles in the plants were compared using the LC/TOF-MS responses. This is the first thorough report of phenolic compounds in hybrid bilberry. In total, 51 different phenolic compounds were identified, including flavan-3-ols, proanthocyanidins, flavonols and their glycosides, and various phenolic acid conjugates. Of the identified compounds, 35 were detected in bilberry, 36 in lingonberry, and 46 in the hybrid. To our knowledge, seven compounds were previously unreported in Vaccinium genus and many of the compounds are reported for the first time from bilberry and lingonberry.

Characterization of the interaction between Actinin-Associated LIM Protein (ALP) and the rod domain of alpha-actinin

Background

The PDZ-LIM proteins are a family of signalling adaptors that interact with the actin cross-linking protein, α-actinin, via their PDZ domains or via internal regions between the PDZ and LIM domains. Three of the PDZ-LIM proteins have a conserved 26-residue ZM motif in the internal region, but the structure of the internal region is unknown.

Results

In this study, using circular dichroism and nuclear magnetic resonance (NMR), we showed that the ALP internal region (residues 107–273) was largely unfolded in solution, but was able to interact with the α-actinin rod domain in vitro, and to co-localize with α-actinin on stress fibres in vivo. NMR analysis revealed that the titration of ALP with the α-actinin rod domain induces stabilization of ALP. A synthetic peptide (residues 175–196) that contained the N-terminal half of the ZM motif was found to interact directly with the α-actinin rod domain in surface plasmon resonance (SPR) measurements. Short deletions at or before the ZM motif abrogated the localization of ALP to actin stress fibres.

Conclusion

The internal region of ALP appeared to be largely unstructured but functional. The ZM motif defined part of the interaction surface between ALP and the α-actinin rod domain.

Octaketide-producing type III polyketide synthase from Hypericum perforatum is expressed in dark glands accumulating hypericins

Hypericins are biologically active constituents of Hypericum perforatum (St John's wort). It is likely that emodin anthrone, an anthraquinone precursor of hypericins, is biosynthesized via the polyketide pathway by type III polyketide synthase (PKS). A PKS from H. perforatum, HpPKS2, was investigated for its possible involvement in the biosynthesis of hypericins. Phylogenetic tree analysis revealed that HpPKS2 groups with functionally divergent non-chalcone-producing plant-specific type III PKSs, but it is not particularly closely related to any of the currently known type III PKSs. A recombinant HpPKS2 expressed in Escherichia coli resulted in an enzyme of approximately 43 kDa. The purified enzyme catalysed the condensation of acetyl-CoA with two to seven malonyl-CoA to yield tri- to octaketide products, including octaketides SEK4 and SEK4b, as well as heptaketide aloesone. Although HpPKS2 was found to have octaketide synthase activity, production of emodin anthrone, a supposed octaketide precursor of hypericins, was not detected. The enzyme also accepted isobutyryl-CoA, benzoyl-CoA and hexanoyl-CoA as starter substrates producing a variety of tri- to heptaketide products. In situ RNA hybridization localized the HpPKS2 transcripts in H. perforatum leaf margins, flower petals and stamens, specifically in multicellular dark glands accumulating hypericins. Based on our results, HpPKS2 may have a role in the biosynthesis of hypericins in H. perforatum but some additional factors are possibly required for the production of emodin anthrone in vivo.

The effect of oral contraceptives on the pharmacokinetics of melatonin in healthy subjects with CYP1A2 g.-163C>A polymorphism

The effect of oral contraceptives (OCs) on melatonin metabolism was studied in 29 subjects genotyped for CYP1A2 SNP g.-163C>A polymorphism. Plasma melatonin and 6-OH-melatonin concentrations were measured after a 6-mg dose of melatonin using a validated liquid chromatography/mass spectrometry method. The mean melatonin AUC and C(max) values were 4- to 5-fold higher in OC users than in non-OC users (P < .0001), whereas the weight-adjusted clearance was significantly lower in OC users (P < .0001). No significant difference in melatonin pharmacokinetics between the genotypes and no additional effect by the genotype on the OC-induced increase in melatonin exposure were evident. Melatonin exposure had no significant effect on the subjects' state of alertness. In conclusion, a significant inhibitory effect of OCs on the CYP1A2-catalyzed melatonin metabolism was seen; thereby, OC use can alter CYP1A2-phenotyping results.

Backbone NMR assignment of the internal interaction site of ALP

Earlier reports have shown that ALP has an internal interaction site. We were able to stabilize the structure of this unfolded part to a great extent by aspartic acid, which allowed the backbone assignment. No secondary structure of the polypeptide was observed.

A giant outburst two years before the core-collapse of a massive star

The death of massive stars produces a variety of supernovae, which are linked to the structure of the exploding stars. The detection of several precursor stars of type II supernovae has been reported (see, for example, ref. 3), but we do not yet have direct information on the progenitors of the hydrogen-deficient type Ib and Ic supernovae. Here we report that the peculiar type Ib supernova SN 2006jc is spatially coincident with a bright optical transient that occurred in 2004. Spectroscopic and photometric monitoring of the supernova leads us to suggest that the progenitor was a carbon-oxygen Wolf-Rayet star embedded within a helium-rich circumstellar medium. There are different possible explanations for this pre-explosion transient. It appears similar to the giant outbursts of luminous blue variable stars (LBVs) of 60-100 solar masses, but the progenitor of SN 2006jc was helium- and hydrogen-deficient (unlike LBVs). An LBV-like outburst of a Wolf-Rayet star could be invoked, but this would be the first observational evidence of such a phenomenon. Alternatively, a massive binary system composed of an LBV that erupted in 2004, and a Wolf-Rayet star exploding as SN 2006jc, could explain the observations.

Characterization of phenolic compounds from lingonberry (Vaccinium vitis-idaea)

Phenolic compounds from the lingonberry (Vaccinium vitis-idaea) were identified using LC-TOFMS, LC-MS/MS, and NMR experiments. The compounds were extracted from the plant material using methanol in an ultrasonicator and further isolated and purified using solid-phase extraction and preparative liquid chromatographic techniques. A total of 28 phenolic compounds were at least tentatively identified, including flavonols, anthocyanidins, catechins and their glycosides, and different caffeoyl and ferulic acid conjugates. This is apparently the first report of coumaroyl-hexose-hydroxyphenol, caffeoyl-hexose-hydroxyphenol, coumaroyl-hexose-hydroxyphenol, quercetin-3-O-alpha-arabinofuranoside, kaempferol-pentoside, and kaempferol-deoxyhexoside in the plant, and the flavonol acylglycosides quercetin-3-O-[4' '-(3-hydroxy-3-methylglutaroyl)]-alpha-rhamnose and kaempferol-3-O-[4' '-(3-hydroxy-3-methylglutaroyl)]-alpha-rhamnose are presented here for the first time ever. In addition, more detailed structure in comparison to earlier reports is described for some compounds previously known to exist in lingonberry.

B-myc: N-terminal recognition of myc binding proteins

B-Myc is an endogenous, N-terminal homologue of transcription factor c-Myc that lacks the C-terminal DNA binding and protein dimerization domain of c-Myc. Clinical mutations in the c-Myc N-terminal region, and the subsequent misregulation of Myc, are implicated in the development of numerous human cancers. Myc functions to both activate and repress transcription by associating with multiple binding partners. We investigated the structural and dynamical properties of B-Myc, free or associated with the transactivation inhibitor, MM-1, and the activator, TBP, using NMR spectroscopy. B-Myc has no persistent tertiary structure, yet regions corresponding to Myc homology boxes 1 and 2 (MBI and MBII, respectively) have molten globule-like characteristics. B-Myc binds to MM-1 in a specific manner without becoming highly structured. The local regions of B-Myc involved in binding differ for MM-1 and TBP, and regions not identified by mutagenesis are found to be involved in MM-1 binding. The results provide new insights into Myc N-terminal protein-protein interactions. We propose a model for Myc regulation through differential involvement of MBI and MBII in the binding of Myc interacting proteins.

Structural basis for the requirement of two phosphotyrosine residues in signaling mediated by Syk tyrosine kinase

The protein-tyrosine kinase Syk couples immune recognition receptors to multiple signal transduction pathways, including the mobilization of calcium and the activation of NFAT. The ability of Syk to regulate signaling is influenced by its phosphorylation on tyrosine residues within the linker B region. The phosphorylation of both Y342 and Y346 is necessary for optimal signaling from the B cell receptor for antigen. The SH2 domains of multiple signaling proteins share the ability to bind this doubly phosphorylated site. The NMR structure of the C-terminal SH2 domain of PLCgamma (PLCC) bound to a doubly phosphorylated Syk peptide reveals a novel mode of phosphotyrosine recognition. PLCC undergoes extensive conformational changes upon binding to form a second phosphotyrosine-binding pocket in which pY346 is largely desolvated and stabilized through electrostatic interactions. The formation of the second binding pocket is distinct from other modes of phosphotyrosine recognition in SH2-protein association. The dependence of signaling on simultaneous phosphorylation of these two tyrosine residues offers a new mechanism to fine-tune the cellular response to external stimulation.

Malignancies after heart transplantation: presence of Epstein-Barr virus and cytomegalovirus

The presence of Epstein-Barr virus (EBV), human papilloma virus (HPV), and cytomegalovirus (CMV) was studied in 20 patients who developed malignancies after heart transplantation in the Helsinki University Central Hospital. The tumors were analyzed for the presence of HPV by polymerase chain reaction and for EBV by in situ hybridization. Clinical CMV infection was verified by immunochemical quantitation of CMV antigen in peripheral blood cells. HPV was detected in one of the eight epithelial malignant tumors studied. Three of the six lymphomas were positive for EBV. Two (67%) of 3 patients with EBV-positive lymphomas and one (33%) of the other three lymphomas but only 2 (14%) of 14 patients who developed other malignancies had a history of a manifest post-transplantation CMV infection prior to the development of malignancy. These results confirm the presence of EBV in lymphomas of heart transplant recipients and suggest that CMV might have a contributory role in the development of EBV-associated lymphomas.

Airway anastomotic healing in the rat tracheal autograft

The healing of airway anastomoses after tracheal autotransplantation was studied in a rat model. Tracheal autotransplantation in length of five tracheal cartilaginous rings was performed in 46 PVGr1 female rats. The animals were sacrificed and divided into six groups as follows: 0-day control group, and 3-, 7-, 14-, 21- and 28-day study groups (n = 6-7/group). In laser Doppler measurements, blood flow was significantly increased in the lower anastomosis after day 7 and in the upper anastomosis after day 21 compared with the control group (p < 0.05). The breaking strength of the tracheal autograft increased after day 7 compared with the control group (p < 0.05). The total collagen content of the lower anastomosis was significantly decreased on days 3 and 7 compared with the control group (p < 0.05), but thereafter it increased constantly. In the upper anastomosis on days 3 and 7, there were significant histological alterations, especially in the tracheal epithelium, compared with the control group (p < 0.05). Tracheal anastomosis is most vulnerable during the first 7 days.

Major surgery increases serum levels of vascular endothelial growth factor only temporarily

BACKGROUND

Vascular endothelial growth factor (VEGF) is a hypoxia-induced endothelial cell-specific mitogen, which is angiogenic in vivo and up-regulated in several malignancies. VEGF can be used as a prognostic marker, but the effect of surgical trauma on serum VEGF (S-VEGF) concentrations is unknown and might reduce the value of VEGF as a serum marker.

METHODS

We monitored S-VEGF levels by enzyme-linked immunosorbent assay in patients undergoing surgery.

RESULTS

Eighteen patients with major surgery had slightly elevated S-VEGF compared with the preoperative level (median 9.5 pg/mL) on the first (median 35 pg/mL; P = 0.0002) and third (median 19 pg/mL; P = 0.004) postoperative day, but not in later samples. The levels measured in 8 patients after minor surgery did not differ from the preoperative levels (P = 0.14).

CONCLUSIONS

Even major surgery is associated only with a slight and transient increase in S-VEGF levels, and, therefore, is unlikely to interfere markedly with the use of VEGF as a prognostic marker.

Donor lung pretreatment with prostaglandin E(1) does not improve lung graft preservation

Prostaglandin E(1) (PGE(1)) is widely used to improve early graft function after lung transplantation, but some studies have questioned its benefits. Therefore we evaluated the effect of donor pretreatment with PGE(1) in our porcine model of single lung transplantation. Donors received PGE(1) or placebo intravenously before flushing the pulmonary artery with modified Euro-Collins solution. After cold storage, the excised left lung was transplanted. Ischemic time was 4 h. We used our right side heart bypass model to measure standardized pulmonary vascular resistance and to study blood flow distribution between recipient's native and transplanted lung. Systemic and pulmonary hemodynamics and gas exchange were also measured. After transplantation, pulmonary vascular resistance was significantly higher in the transplanted lung, which received only one fourth of the total pulmonary blood flow. PGE(1) pretreatment did not improve pulmonary hemodynamic parameters, or gas exchange.

Surgery for lung cancer in the elderly

In order to assess the appropriateness of lung cancer surgery in the elderly and determine optimal subjects and resection procedure, 75 patients operated on in 1976-1996 at age > or =75 years (including 13 > or =80) were followed up. The operations included limited resection (8), lobectomy (47), bilobectomy (10) and pneumonectomy (10) and were judged to be radical in 59 cases (79%). Perioperative mortality was 9% and morbidity 29%, including 21% major complications. Cumulative 5-year survival was 32%, in stages IA-IIB 27-41%, and cancer-related survival 61-79%. Mortality did not differ significantly between resection types, but morbidity did. Nor did mortality, morbidity or survival differ between the age groups 75-79 and > or =80 years. In stage I cancer there was no significant difference in survival or cancer-related survival after lobectomy vs limited resection. We conclude that age, even >80 years, is not incompatible with curative resection. Lobectomy is the treatment of choice, but a less radical resection may be advisable if there is comorbidity. If more extensive resection is performed, the individual surgical risk must be weighed against the potential long-term benefit.

Emergency surgery of non-ruptured abdominal aortic aneurysm

BACKGROUND AND AIMS

The pain of an abdominal aortic aneurysm (AAA) is believed to signify rupture, and emergency surgery for symptomatic AAA is a widely accepted practice to prevent rupture. To clarify the benefit of emergency surgery we evaluated the clinical course of emergency treated patients with non-ruptured AAAs.

MATERIAL AND METHODS

110 patients (90 men, mean age 69, range 49-93; 20 women, mean age 75, range 63-89) underwent emergency repair of non-ruptured AAA between 1970 and 1992 at the Department of Thoracic and Cardiovascular Surgery of Helsinki University Central Hospital (HUCH). Survival rates after surgery were analysed using product-limit-survivorship method. The survival rates after age-stratification were compared with those of patients undergone elective surgery (n=599) or emergency surgery because of ruptured AAAs (n=363) during the same period. Risk factors affecting early and late survival rates after operation were analysed by logistic regression analysis and Cox proportional hazard model.

RESULTS

Thirty-day operative mortality rates were 18 % (20/110) in the emergency non-ruptured group, compared with 7 % (42/599) in the elective group and 49 % (179/363) in the ruptured group (p<0.05). Thirty day survival rate was not changed among the nonruptured emergency group from 1970 to 1992, whereas the rates of ruptured and elective groups became better during the study period. Late survival rates for 30-day postoperative survivors were clearly reduced among the non-ruptured emergency group, without difference between the emergency operated ruptured and non-ruptured groups. Coronary artery disease was decreasing significantly early and late survival rates after emergency surgery for non-ruptured AAAs (p<0.05, logistic regression and p<0.001 Cox proportional hazard).

CONCLUSIONS

Early and late mortality risk is significantly higher (p<0.001) after emergency surgery for haemodynamically stable non-ruptured AAA than after elective surgery, mainly because of coronary artery disease.

Cardiomyocyte apoptosis and progression of heart failure to transplantation

BACKGROUND

Cardiomyocyte apoptosis has been found in congestive heart failure, but its clinical significance has been difficult to study. We compared the occurrence of cardiomyocyte apoptosis in explanted hearts with the progression of severe heart failure until the need for transplantation.

DESIGN

Using the TUNEL assay, apoptotic cardiomyocytes were quantified in explanted failing hearts from patients with either idiopathic dilated cardiomyopathy (n = 21) or ischaemic heart disease (n = 14). The percentage was compared with the clinical severity and progression of endstage heart failure. Samples obtained at autopsy and during open heart surgery served as controls.

RESULTS

The number of apoptotic cardiomyocytes was significantly increased in failing hearts regardless of aetiology (medians 0.075% in ischaemic heart disease and 0.119% in dilated cardiomyopathy) compared with control myocardium. In patients with dilated cardiomyopathy, apoptotic cardiomyocytes were more numerous in subjects with a rapidly deteriorating clinical course (0.192%, n = 10) than in patients with intermediate (0.093%, n = 6, P = 0.03) or slow (0.026%, n = 5, P = 0.003) progression. No such association was observed in patients with ischaemic heart disease, in whom we found significantly increased cardiomyocyte apoptosis adjacent to scars of previous infarctions (0.576%) in contrast to the diffuse distribution seen in dilated cardiomyopathy. Expression of Bcl-2, an antiapoptotic protein, was increased in all failing hearts by immunohistochemistry.

CONCLUSION

Cardiomyocyte apoptosis is a consistent feature of end-stage heart failure in man and appears to be quantitatively related to the clinical severity of deterioration in dilated cardiomyopathy. Increased expression of Bcl-2 in cardiomyocytes indicates activation of an antiapoptotic response. These observations suggest that cardiomyocyte apoptosis is a clinically relevant and potentially modifiable pathophysiological phenomenon in severe heart failure.

Thoracic duct cyst: a case report and review of 29 cases

Cysts of the thoracic duct are rare. We report a case of a cervical thoracic duct cyst and review 29 thoracic duct cysts reported previously (19 mediastinal, 9 cervical, and 1 abdominal). The mean age of the patients was 47.6 years (range 17 to 86 years). Fourteen (46.7%) of the patients were asymptomatic. When symptoms were present, they ranged from retrosternal pain, dysphagia, and dyspnea to respiratory insufficiency and superior vena cava compression. Diagnosis of the cyst can be made after computed tomography or ultrasonography. The cystic fluid contains T lymphocytes and triglycerides in excess. The symptoms in a patient with a thoracic duct cyst are related to compression of adjacent structures. The most profound symptoms are likely to be produced by mediastinal cysts above the aortic arch. Treatment consists of surgical removal of the cyst and ligation of all lymphatics connected to the cyst.

Ganciclovir prophylaxis after lung and heart-lung transplantation

Cytomegalovirus (CMV) infection causes both acute and chronic allograft damage. The aim of this study was to analyze the utility of ganciclovir in preventing CMV infection in pulmonary allografts. Thirty five consecutive lung (LTX) and heart-lung (HLTX) transplant patients were studied from 1990 to 1996. CMV prophylaxis was started in January 1995. Recipients with CMV-positive serology received ganciclovir on postoperative days (POD) 7-28. Acyclovir was given on POD 29-90. Recipients with CMV-negative serology received ganciclovir on POD 7-90 if the serology of the donor was positive. CMV was demonstrated by rapid cell vial culture and/or detecting CMV-specific antigens in bronchoalveolar lavage (BAL) samples. The time point of the first BAL fluid specimen exhibiting CMV was estimated using the Life Table method. BAL samples of all the recipients without ganciclovir treatment became positive for CMV, whereas two of the 11 patients with ganciclovir administration remained negative. Ganciclovir significantly (P < 0.05) delayed but did not absolutely prevent CMV infection after LTX and HLTX.

Effects of a new calcium sensitizer, levosimendan, on haemodynamics, coronary blood flow and myocardial substrate utilization early after coronary artery bypass grafting

AIMS

The aim of the study was to evaluate the effects on systemic and coronary haemodynamics and myocardial substrate utilization of a new calcium sensitizer, levosimendan, after coronary artery bypass grafting.

METHODS AND RESULTS

Twenty-three low-risk patients were included in this randomized and double-blind study. They received placebo (n = 8), 8 (n = 8) or 24 (n = 7) micrograms.kg-1 of levosimendan after coronary artery bypass operation. Systemic and coronary sinus haemodynamics with thermodilution and myocardial substrate utilization were measured. The heart rate increased 11 beats.min-1 after the higher dose (P < 0.05). Cardiac output increased by 0.7 and 1.61.min-1 (P < 0.05 for both) after 8 and 24 micrograms.kg-1 of levosimendan, respectively. Systemic and pulmonary vascular resistance decreased significantly after both doses. Coronary sinus blood flow increased by 28 and 42 ml/(P = 0.054 for the combined effect) after the lower and higher dose, respectively. Myocardial oxygen consumption or substrate extractions did not change statistically significantly.

CONCLUSION

Despite improved cardiac performance, levosimendan did not increase myocardial oxygen consumption or change myocardial substrate utilization. Thus levosimendan has the potential to treat low cardiac output states after cardiopulmonary bypass surgery.

Minimally invasive coronary artery bypass grafting using the right gastroepiploic artery

BACKGROUND

Anastomosis of the left internal thoracic artery to the left anterior descending artery without sternotomy and without cardiopulmonary bypass is a standard approach in minimally invasive coronary artery bypass grafting. To expand the indications for minimally invasive coronary artery bypass grafting from one-vessel disease to two-vessel disease, we began to perform anastomosis of the right gastroepiploic artery (RGEA) to the right coronary artery (RCA).

METHODS

From February to November 1996, an RGEA graft was used in 25 of the 100 patients who underwent minimally invasive coronary artery bypass grafting at our clinic. Eleven of the patients had only RCA disease and 14 had both RCA and left anterior descending artery disease. One of the operations was a redo coronary artery bypass grafting. The RGEA was anastomosed to the RCA through a laparotomy incision and the left internal thoracic artery was anastomosed to the left anterior descending artery through a left anterior thoracotomy. In 5 patients, the RGEA was lengthened by venous grafting.

RESULTS

All patients underwent angiography after operation; 82.6% of the RGEA grafts and all the left internal thoracic artery grafts were functioning well. In three of the four nonvisualized RGEA grafts, the percentage of proximal stenosis of the RCA seen on postoperative angiography was not critical (40%, 50%, and 50%, respectively), allowing significant competitive flow through the native bypassed RCA. The patency of all the RGEA grafts without competitive flow was 95%, with a 95% confidence interval of 75.1% to 99.9%.

CONCLUSIONS

The indications for minimally invasive coronary artery bypass grafting could be extended to primary operations in patients with left anterior descending artery and RCA lesions by using both the left internal thoracic artery and the RGEA.

St. Jude versus CarboMedics: follow-up after prosthetic valve replacement

BACKGROUND

The purpose of the present study was to evaluate the immediate and long-term outcome of patients with two types of mechanical bileaflet heart valves operated on in the same institution by the same group of surgeons.

METHODS

A comparative analysis was made in 229 consecutive patients receiving either the St. Jude Medical (SJM) or CarboMedics (CMS) bileaflet mechanical valve in 1990-1991. There were no differences in the preoperative demographics between the two groups. At operations simultaneous coronary bypass operation was performed in 40 patients out of 134 (30%) in the SJM group and 95 (44%) in the CMS group (p=0.026). Sixteen patients in the SJM group underwent replacement of the ascending aorta with a composite graft and none in the CMS group.

RESULTS

There was no difference in hospital mortality between the SJM (6.7%) and CMS (6.3%) groups or in other immediate postoperative complications. The patients were followed up to 32 months. There were more patients in the NYHA class I and II in the CMS group (88%) than in the SJM group (69%), p<0.002. Three were 11 thromboembolic events (0.051% per patient year) in the SJM group and one thromboembolic event (0.008% per patient year) in the CMS group. There were no other differences between the groups in long-term survival, rate of bleeding, infective endocarditis or perivalvular leakage.

CONCLUSIONS

With the exception of a little more favourable exercise tolerance and fewer thromboembolic events in the CMS group there were no other differences in the outcome of patients with these two types of bileaflet mechanical valves.

En bloc heart and lung transplantation in Finland 1988-1996

The purpose of the study was to review the first clinical experience in combined heart-lung transplantation in our institution.

MATERIAL

From June 1988 to December 1996 15 en bloc heart and lung transplantations were performed. There were nine men and six women, aged 17-61 (mean 42.3) years. The indications for operation were primary pulmonary hypertension with right heart failure in five, Eisenmenger's syndrome in five, pulmonary embolism and right heart failure in three and emphysema with right heart failure in two cases.

RESULTS

The hospital (30 day) mortality was four patients (26.6%). The causes of mortality were graft failure in two cases, infection and bleeding after transbronchial biopsy in one case and sepsis and aspergillosis in one case. Postoperative complications included eight cytomegalovirus (CMV), two Pneumocystis Carinii, five bacterial and five fungal (one Aspergillus and four Candida) infections. Rejection episodes (of the lungs) occurred in four patients (in 27%). During the follow-up to four years two patients developed diabetes mellitus (insulin therapy), one patient renal failure (dialysis), two patients tracheal stricture (laser resection), one patient fracture of the spine and one patient epilepsy. One patient died from prolonged CMV infection and chronic rejection eight months postoperatively. Four patients underwent bronchial artery revascularization (two with the internal thoracic artery and two with a vein graft). This was followed by improved airway healing and resistance towards infections. After a follow-up to four years 10 patients out of 15 (66.7%) were living an active life.

CONCLUSION

Combined heart-lung transplantation offers a good mid-term outcome for patients with end-stage cardiopulmonary disease. The results compare favourably with the corresponding international statistics.

Assessment of xanthine oxidase in human lung and lung transplantation

Oxygen free radical generation by xanthine oxidase (XO) is a possible mechanism in the injury following reperfusion of transplanted organs. This study was undertaken to investigate XO in human lung, and to investigate whether XO is released into the blood stream during the immediate postoperative period after lung transplantation. XO activity was measured in healthy human lung tissue, and XO protein and the adenine nucleotide catabolic products hypoxanthine, xanthine and uric acid were analysed in the plasma samples collected during human heart-lung transplantation (n=4), double lung transplantation (n=2), and single lung transplantation (n=1). Neutrophil degranulation was assessed by plasma lactoferrin measurements. The results indicated that XO activity (detection limit 5 pmol x min(-1) x mg(-1) protein) and protein (detection limit 5 ng x mg-1 protein) were undetectable in the lungs of five healthy individuals. Similarly, no XO protein could be found in the plasma samples from the right ventricle or left atrium during and after the transplantation in any of the cases. Plasma xanthine and hypoxanthine concentrations were elevated 2-10 fold immediately after the reperfusion of the transplant, indicating washout of high-energy phosphate degradation products from the ischaemic lung. Plasma uric acid decreased rather than increased immediately after the surgery and during the following 24 h. Lactoferrin was elevated during the surgery. In conclusion, these results show that XO activity in human lung is low, it is not released into the blood stream during human heart-lung transplantation, and it is unlikely to contribute to postoperative complications in these patients.

Heart transplantation in Finland 1985-1995

BACKGROUND AND AIMS

Since improved immunosuppression in the 1980's, heart transplantation is a well established procedure to treat patients with end-stage heart failure. The first heart transplantation in Finland was performed in 1985. Since then the activity has gradually increased to a level of about 25 annual transplants. The aim of this report is to sum up the clinical experience during the first 11 years.

MATERIALS AND METHODS

From February 1985 till the end of 1995, 190 heart transplantations were performed in our institution. There were 176 males and 14 females ranging from 15 to 62 (mean 42.2) years of age. End-stage preoperative cardiac disease was dilating cardiomyopathy in 108 cases, coronary artery disease in 65 cases, valvular disease in 12 cases and congenital heart disease in five cases.

RESULTS

The 30-day hospital mortality was 29 out of 190 (15.2%). The actuarial survival was 77% at one year, 75% at two years and 73% at 10 years. The most common causes of death were rejection (11 cases), graft failure (11 cases), abdominal complications (six cases) and cytomegalovirus (CMV) infection (four cases). A total of 87 rejection episodes occurred in 53 patients consisting 28 per cent of patients. 44 rejections occurred within three months post transplantation. Significant infections were noted in 198 instances in 97 patients. These were of bacterial origin in 92, viral in 48, fungal in 12 and protozoal in 10 cases, and 36 such infections which responded to antibiotics favourably but in which the microbe remained unidentified. 138 infections (i.e. 80%) occurred within 6 months post transplantation. In viral infections cytomegalovirus (CMV) predominated (29 out of 48). The CMV infection was significantly milder in patients who were seropositive preoperatively than in preoperatively seronegative patients with seropositive donors. CMV infection was associated with increased risk of post-transplant coronary artery disease. Three years after transplantation some restoration of sympathetic nervous response was observed at orthostatic test in heart rate and blood pressure.

CONCLUSIONS

It can be concluded that 1) if a patient survives the three immediate postoperative months, his prognosis is good for the forthcoming years, 2) clinically significant rejections occur in less than one third of the patients, 3) cytomegalovirus is the most harmful agent post transplantation and a risk factor for post-transplant coronary artery disease and that 4) some restoration of sympathetic nervous control of the heart occurs within three years after transplantation.