Characteristics and Outcomes of Recipients of Heart Transplant with Coronarvirus Disease 2019 Who Received Casirivimab Plus Imdevimab Infusion

Purpose

Heart transplant (HT) recipient are at increased risk of adverse outcomes following COVID-19 infection and may benefit from monoclonal antibody infusion to mitigate progression to clinically severe disease. The aim of this study is to describe the outcomes of HT patients who experienced mild to moderate coronavirus disease 2019 (COVID-19), with subsequent administration of casirivimab plus imdevimab administration.

Methods

A retrospective review of all HT recipients who were infected with COVID-19, and subsequently infused with monoclonal antibodies in a large academic medical center between January 1, 2021 to September 1, 2021.

Results

14 HT patients were included in the analysis. The median age was 57.5 (interquartile range [IQR], 41.5-64) years, 10 (71%) were men, and median time from HT was 3.48 (IQR, 1.00-11.82) years. Comorbid conditions included hypertension in 6 patients (43%), diabetes in 4 (29%), and chronic kidney disease in 6 (43%). Eight patients (57%) were previously vaccinated, predominantly with the Pfizer-BioNTech vaccine. Three participants (21%) were admitted after clinical progression of COVID-19. Among patients managed at the study institution, mycophenolate mofetil was discontinued in two patients (14%) and calcineurin inhibitor was maintained at previous levels in all fourteen patients (100%). Of the admitted patients, 1 was treated with high dose corticosteroids alone and 2 were treated with corticosteroids plus remdesivir. No patient required intubation. All 3 patients were discharged home and no patients in this cohort died.

Conclusion

In this single-center case series, HT patients with mild-moderate COVID-19 who were treated with monoclonal antibody infusion had a hospitalization rate of 21% and 100% survival. Further studies are required to optimize management of COVID-19 infection in the HT population.

Health-related quality of life in patients with recurrent pericarditis: results from RHAPSODY, a phase 3 study of rilonacept

Background

Recurrent pericarditis (RP) patients report that painful, debilitating flares negatively impact their health-related quality of life (HRQoL). RHAPSODY, the Phase 3 trial of rilonacept (IL-1α/IL-1β cytokine trap), included a daily pain diary and patient-reported outcome SF-36v2 to measure HRQoL throughout the trial.

Purpose

The purpose of this research is to evaluate the effect of rilonacept on HRQoL in relation to changes in pain for RP patients who have a recurrence.

Methods

RHAPSODY enrolled 86 patients with acute symptomatic RP to receive weekly rilonacept for a 12-week run-in (RI) period and randomized 61 patients (1:1) to receive placebo (n=31) or continue rilonacept (n=30) for the event-driven randomized-withdrawal (RW) period. Patients on placebo who experienced a qualifying recurrence during RW (return of pericarditis pain and increase in C-reactive protein) were rescued with bailout rilonacept. Patients reported daily pericarditis pain electronically, using a 0–10 numeric rating scale (NRS), and completed the SF-36v2 at study visits prior to clinician interaction. Scores from RI Baseline (BL), RI Week 12 (RW BL), Recurrence visit, and RW up to Week 24 (or end of study; EOS) were evaluated for patients who experienced recurrence in RW. Analyses exclude one patient randomized to placebo who had a recurrence after Week 24 of the RW period.

Results

Analyses focused on the 22 of 30 patients (73%) in the placebo group who experienced a recurrence before Week 24 of RW (median time from RW BL to recurrence: 8.6 weeks). During RI, daily pain scores decreased while on rilonacept (Cohen's effect size [ES] d=−2.0), and SF-36v2 scores improved, with scores at RI BL (Fig. 1 red line) below the general population average of 50 and near or above average at RI Week 12 (Fig. 1 blue line); ES were all large (d>0.8), ranging from 0.917 (Mental Component Summary) to 2.021 (Bodily Pain). At recurrence, pain scores increased (d=6.5; Fig. 2) and SF-36v2 scores were below the population average (Fig. 1 orange line), with largest reductions between RI Week 12 (RW BL) and recurrence for Bodily Pain (−13.4) and Physical Component Summary (−10.6). Following rilonacept bailout, average pain decreased (d=−2.1; Fig. 2), and by RW Week 24/EOS, SF-36v2 scores returned to similar levels as at the end of the RI period (Fig. 1 green line).

Conclusion

Impaired RI BL SF-36v2 scores indicate negative impact of RP on HRQOL in RP patients. While receiving rilonacept, HRQoL scores improved to near or above population averages, in conjunction with patient-reported pain. After discontinuing rilonacept during RW, HRQoL scores worsened at recurrence and improved upon receipt of bail-out rilonacept, similar to pain. These results provide support for the broader benefit of rilonacept treatment beyond pain, when administered on top of conventional therapies and as mono-therapy, providing evidence of its potential to improve HRQoL in this patient population.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Kiniksa Pharmaceuticals, Ltd.

Gender variability in the clinical phenotype of hypertrophic cardiomyopathy

Introduction

Hypertrophic cardiomyopathy (HCM) is a structural heart disease defined by an increase in left-ventricular (LV) wall thickness, that may be complicated with a clinical syndrome of heart failure, arrhythmia and death.

Purpose

To characterize the clinically significant factors for female HCM patients and bring forward the awareness to gender-based differences in HCM.

Methods

We reviewed the patient records of 1297 patients age ≥18 years, diagnosed with HCM, from two tertiary medical centers in Spain and Israel, and analyzed 748 male and female patients matched for age ≥60 years at admission, BMI, hypertension, diabetes and obstructive HCM.

Results

Female patients were older at original diagnosis [median 54 years (38–66) vs. 50 years (35–60), p=0.007], and had higher rates of family history of both HCM (46% vs. 37%, p=0.01) and sudden cardiac death (23% vs. 15%, p=0.02). Female patients had lower rates of active smoking (11% vs. 25%, p<0.001) and coronary disease (3% vs. 8%, p=0.007). In echocardiographic studies, females had a smaller LV cavity both during diastole [median 42mm (39–46) vs. 46 (42–50), p<0.001] and during systole [median 24 (21–29) vs. 27 (23–31), p<0.001]. Female patients had higher rates of significant mitral insufficiency (37% vs. 19%, p<0.001), and despite no significant differences in the rates of obstructive HCM, diastolic dysfunction, left-atrial enlargement, atrial fibrillation, ventricular tachyarrhythmia or pulmonary disease, they also had more significant pulmonary hypertension (≥45mmHg, 29% vs. 14%, p<0.001). Women had a lower functional capacity (p<0.001 for differences in NYHA, see fig.), and lower exercise capacity [median 7.0 METs (5–10) vs. 10.0 (7–12), p<0.001) and more abnormal blood pressure response to exercise (35% vs. 26%, p=0.03). Electrocardiographic features were similar across genders, except for a non-clinically significant shorter QRS duration in females. No significant differences were seen in 5-year mortality follow-up, which was ∼3% in the entire cohort.

Conclusions

Female patients suffering from HCM have a clinical phenotype defined by slightly later presentation (and shorter time until admission to a tertiary-center cardiomyopathy clinic), smaller LV cavity size, higher severity of mitral insufficiency and pulmonary hypertension and worse functional and exercise capacities. Genders did not differ in 5-year mortality, which was relatively low.

Functional and exercise capacity

Funding Acknowledgement

Type of funding source: None

Management and outcome of acute and recurrent pericarditis during pregnancy

Background

Pericarditis in pregnancy is uncommon. Treatment options, including NSAIDs and long term gluco-corticosteroids (CS) have extensive side-effects, while data on the use of Colchicine in pregnant women who suffer from pericarditis is limited.

Objective

To evaluate the management and outcome of active pericarditis during pregnancy in both acute (AP) and recurrent pericarditis (RP) patients.

Methods and results

Twelve pregnant women (14 pregnancies) with active pericarditis were followed prospectively in our cardiology-pregnancy clinic; 6 with AP and 8 with RP. Etiology: 11 idiopathic, 2 post-pericardiotomy syndrome and 1 Q fever. Maternal age on presentation was 27±4y vs. 33±3y in RP vs AP respectively. Average gestational age upon diagnosis was lower in RP than in AP (18 weeks, range 6–30 vs 26 weeks, range 5–35). In the RP group, 7/8 women (87%) were treated with CS compared with 2/6 women (33%) in the AP group; 3 women in RP group (37%) failed to respond to subsequent treatment with azathioprine and 1 patient was treated successfully with Anakinra. Colchicine was prescribed in 13/14 (93%) of pregnancies, average colchicine exposure during pregnancy was 25±15 weeks. Recurrence during pregnancy: 6/8 (75%) of RP; 2/6 (33%) of the AP, all of them on CS. All pregnancies culminated in a live birth with a mean gestational age on delivery of 37±1.4 weeks. Average birthweight was 3267±507 grams. There were no fetal anomalies or developmental delays after a mean follow-up of 2.7 years. All newborns and maternal outcomes were normal. On long term follow-up after delivery RP patients treated with colchicine developed less recurrences.

Conclusion

Active pericarditis is associated with a high recurrence rate during pregnancy despite treatment with CS. Colchicine use in pregnant women with active pericarditis appears to be safe.

Funding Acknowledgement

Type of funding source: None

Serum lactate levels are an independent marker for complications in acute pulmonary embolism: from the PERT registry

Introduction

Serum lactate is a marker for the presence and severity of imbalances between tissue oxygen supply and demand. There are only scare data regarding the significance of arterial lactate in PE patients.

Purpose

We sought to explore the significance of venous serum lactate as a short- and long-term predictor of adverse outcomes.

Methods

We prospectively enrolled 570 patients with topographically-confirmed pulmonary embolism, hospitalized in our center during 2016–2019. Patient's data was collected using an electronic medical record and follow-up interviews via telephone. The combined end point of hemodynamic instability, shock, mechanical ventilation, or need for CPR was prospectively documented during hospitalization as well as 1-year mortality.

Results

The analysis included 461 consecutive patients with available clinical data including venous lactate. The median age was 69 years, and 262 (58%) were female. Median serum lactate levels were 21 mg/dL (IQR 16–31). The composite endpoint was documented in 92 patients (20%), and lactate levels above 21 mg/dl had a higher incidence of the composite end point (26% vs, 14%, p=0.002). Similar findings were seen when adding either the need for escalating therapy (44% vs. 24%, p<0.001), in-hospital mortality (31% vs. 16%, p=0.001) or 30-day mortality (27% vs. 21%, p<0.001) to the previous composite. One-year mortality was significantly higher in the higher lactate group (17% vs 5%, p<0.001), and a lactate level above 21 mg/dL was independently associated with 1-year mortality in a Cox-regression model adjusted for age, gender and a history of heart failure or malignancy, HR 2.5 (95% CI 1.7–3.9).

In subgroup analyses, lactate levels were associated with 1-year mortality regardless of age or gender. Similar predictive trends for 1-year mortality were seen in patients stratified by diabetes status, a current malignancy, PE risk and right-ventricle abnormalities (see figure).

Conclusions

Venous serum lactate levels are associated with a myriad of in-hospital adverse outcomes, as well as long-term mortality. In a 1-year follow-up, a higher lactate level was predictive of mortality across various subgroups, with higher hazard ratios seen specifically in lower-risk patients. Further studies are needed in order to evaluate the possible prognostic role of the change in serum lactate during PE management.

Elevated lactate and 1-year mortality

Funding Acknowledgement

Type of funding source: None

Effect of hypokintic transformation on the clinical phenotype and functional capacity in hypertrophic cardiomyopathy

Background

Advanced hypertrophic cardiomyopathy (HCM) may be complicated by a dilated hypokinetic transformation. Reduced left ventricular ejection fraction (HFrEF) has been described in terms of specific risks of morbidity and mortality, and specifically in terms of increased risk for fatal arrhythmias. Nevertheless, recent publications have casted doubt regarding the role of arrhythmia in non-ischemic HFrEF and questioned the role of primary prevention strategies in these cases.

Methods

We've reviewed clinical characteristics of 883 patients age ≥40, diagnosed with HCM who were evaluated in the cardiomyopathy clinic in two tertiary medical centers in Israel and Spain.

Results

Forty-five patients (5%) suffered from hypokinetic transformation. They were younger at diagnosis (median 32 [IQR 24–55] vs. 49 [35–60], p<0.001), had a lower body-mass index (28.4 [±4.7] vs. 26.0 [±3.9], p<0.001), and suffered more from strokes (19% vs 6%, p<0.001). They had lower had a lower NYHA class (p=0.001) and lower exercise capacity (7.3 [4.5–10.8] vs. 9.6 [6.7–12.0] METS, p<0.001). Patients with hypokinetic HCM had higher rates of pacemaker and implanted defibrillator (ICD) implantations (41% vs 11%, p<0.001) and (43% vs 13%, p<0.001) respectively. These patients had a higher incidence of sustained ventricular tachyarrhythmias (14% vs 2%, p<0.001). Among patients who had an ICD, patients suffering from hypokinetic transformation had received more appropriate ICD therapy (27% vs 12%, p<0.001). These patients received more heart transplantations (13% vs 1%, p<0.001), and had a trend for higher incidence rate of Sudden cardiac death (6% vs 2% p=0.06) and a higher 5-year mortality rates (21% vs. 5%, p<0.001).

Conclusions

HCM patients suffering from hypokinetic transformation have lower functional and exercise capacities, are more likely to suffer from ventricular tachyarrhythmias and experience appropriate ICD therapy, and undergo heart transplantation. They also have a significantly lower 5-year survival.

Five-year survival

Funding Acknowledgement

Type of funding source: None

Induction of apoptosis by retinoids in human cervical-carcinoma cell-lines

Retinoids can inhibit the growth and modulate the differentiation of a variety of tumor cell types in vitro and in vivo. All-trans retinoic acid (ATRA) and N-(4-hydroxyphenyl)retinamide (4HPR) are currently being evaluated in clinical trials for their potential use in cancer chemoprevention and therapy. We compared the effects of these retinoids on 10 human cervical carcinoma cell lines. Four of the 10 cell lines showed dramatic morphological changes and the other 5 exhibited decreased cell density after treatment with 10 mu M 4HPR, whereas few changes were induced by 10 mu M ATRA. Cell rounding and detachment were also observed in four of the cell lines. An analysis of DNA from both detached and attached cells after retinoid treatment has demonstrated the formation of a DNA ladder after electrophoresis in agarose gels, which indicated that some of the cell lines had undergone apoptosis. Induction of DNA fragmentation by 4HPR but not by other retinoids (ATRA, 13-cis-RA, and 9-cis-RA) was further evidenced as early as 24 h after treatment by a quantitative assay based on the degradation of [H-3]-thymidine-labeled DNA. Ln addition, morphological changes of nuclei associated with apoptosis such as chromatin condensation were observed by propidium iodide staining of the nuclei after 4HPR treatment. These results demonstrate that 4HPR causes apoptosis in several cervical carcinoma cell lines and that it is more potent in this effect than ATRA or other RA isomers.

Leptin and the post-operative inflammatory response. More insights into the correlation with the clinical course and glucocorticoid administration

BACKGROUND

Cardiac surgery involving cardiopulmonary bypass (CPB) causes a systemic inflammatory process which can lead to multiple organ failure and postoperative morbidity. Recent animal and human studies suggested a possible involvement of leptin in the systemic inflammatory response.

AIM

To characterize the response of leptin to open heart surgery (OHS) and the relationship between the time course of leptin levels and the post-operative clinical course, and to examine the effect of exogenous glucocorticoids.

PATIENTS AND METHODS

Forty-seven pediatric patients, undergoing OHS for congenital heart disease were studied. Thirty-four patients (Group 1) received methylprednisolone during CPB while 13 (group 2) did not. Serial blood samples were collected perioperatively and up to 24 h after surgery, and assayed for leptin and cortisol.

RESULTS

All patients' leptin levels decreased significantly during CPB (to 44-48% of baseline, p<0.001); they then increased, peaking at 12 h post-operatively. The levels of groups 1 and 2 were similar up to 8 h post-operatively; thereafter, those of group 1 were significantly higher. Recovery of leptin levels in patients with a more complicated post-operative course was comparatively slower. Cortisol levels of all patients increased significantly during CPB (p<0.001), gradually decreasing afterwards. Cortisol and leptin levels were inversely correlated in both patients' groups.

CONCLUSIONS

CPB is associated with acute changes in circulating leptin levels. A complicated postoperative course is associated with lower leptin levels which are inversely correlated with cortisol levels. Leptin may participate in post-CPB inflammatory and hemodynamic responses.

Audiometric and imaging characteristics of distal renal tubular acidosis and deafness

Objective:

Primary distal renal tubular acidosis with sensorineural hearing loss is a rare autosomal recessive disease, usually caused by mutations in the ATP6V1B1 gene. The aim of this study was to characterise the phenotype of this disease, with emphasis on the auditory findings, in a cohort of Israeli children.

Study design:

Prospective study of five children, from three unrelated families, with distal renal tubular acidosis and bilateral sensorineural hearing loss, with mutations in the ATP6V1B1 gene.

Methods:

The following were collected from patients' medical records: biochemical and renal data, age at distal renal tubular acidosis diagnosis, and age at hearing loss. Hearing loss progression as well as current hearing status were assessed, and high resolution computed tomography of the temporal bone was performed. All patients underwent genetic testing.

Results:

Four patients were diagnosed with distal renal tubular acidosis before the age of six months and one at 24 months. All had the classical findings of low blood pH and inappropriately high urine pH. Hearing loss was diagnosed between the ages of three months and two years. The hearing loss was bilateral, asymmetrical and progressive, occasionally with a conductive component. Two children underwent cochlear implantation, at ages 10 and 15 years. High resolution computed tomography, performed in four patients between the ages of 2.5 and 15 years, showed bilaterally enlarged vestibular aqueducts. This was the only radiological abnormality in the inner ear in all cases. A different mutation in the ATP6V1B1 gene was found in each family.

Conclusion:

Several types of mutations in the ATP6V1B1 gene may cause distal renal tubular acidosis and sensorineural hearing loss. Patients display a typical progressive type of hearing loss and have enlarged vestibular aqueducts, with no other abnormalities being observed on imaging.

Progressive nephropathy associated with mitochondrial tRNA gene mutation

Mitochondrial DNA plays a crucial role in oxidative production of energy. Thus, defects in mitochondrial DNA can affect virtually all organ systems. The point mutation A --> G at position 3243 in the mitochondrial tRNAleu(UUR) gene is the cause of several distinct types of mitochondrial cytopathy and several clinical phenotypes, including encephalomyopathy with lactic acidosis and stroke-like episodes and maternally inherited diabetes and deafness. This mutation has been recently described also in association with kidney disease, mainly focal and segmental glomerulosclerosis. At present, little is known about the prevalence of this mitochondrial nephropathy, its clinical course and the pathogenesis of glomerular damage. We describe 2 unrelated patients, who presented with proteinuria and progressed to end-stage renal failure. Other clinical features were short stature, severe headache, hearing loss, diabetes mellitus and hypertrophic cardiomyopathy. The main histological finding was an increased number of abnormal mitochondria in tubular cells and podocytes. Analysis of mitochondrial DNA from leukocytes and urine sediment revealed heteroplasmy for the A3243G mutation in tRNAleu(UUR) gene in both patients. Recognition of the characteristic clinical and histological features of the mitochondrial A3243G mutation-associated glomerulopathy will enable correct diagnosis and better management of a disease which is likely to be underdiagnosed.

Analysis of the long-term outcome of surgically corrected vesico-ureteric reflux

OBJECTIVE

To review patients who had vesico-ureteric reflux corrected surgically by ureteric reimplantation during childhood, and thus assess their long-term outcome.

PATIENTS AND METHODS

Between 1970 and 1979, 322 children underwent ureteric reimplantation; 100 (79 women and 21 men) were re-assessed and the long-term results evaluated using a questionnaire, a review of the patients' current medical records and an appointment in the outpatient clinic. The evaluation focused on the frequency of late urinary tract infections (UTIs), current renal function tests, related complications during pregnancy and the incidence of hypertension at least 20 years after surgery.

RESULTS

Of the study group, 51% (66% of men and 47% of women) had no long-term urological complications. The incidence of UTIs was 43% in women and 24% in men, and of pyelonephritis 27% and 9.5%, respectively. Hypertension was detected in 6% of the patients during assessment. There were new renal scars, despite surgery, in 20% of the patients. Forty-seven women had been pregnant, 28% reporting UTIs during pregnancy. In 7% of 94 pregnancies the women also had pre-eclampsia and two women had transient gestational ureteric obstruction which required drainage. Renal functional tests were worse in one man and one woman who developed end-stage renal disease and had a renal transplant.

CONCLUSIONS

This series shows that even patients who were treated successfully by ureteric reimplantation during childhood are prone to recurrent UTIs, progressive renal scarring, hypertension and complications during pregnancy. There is a need to establish a protocol for the long-term follow-up of such patients.

Circulating leptin and the perioperative neuroendocrinological stress response after pediatric cardiac surgery

OBJECTIVE

Leptin may be involved in the acute stress response, regulating inflammatory parameters of major importance after cardiopulmonary bypass (CPB) surgery. Critically ill patients demonstrated significant increases in leptin levels in response to stress-related cytokines (tumor necrosis factor, interleukin [IL]-1) and abolishment of the circadian rhythm of leptin secretion. We characterized the pattern of leptin secretion in the acute postoperative period in children undergoing cardiac surgery and compared the changes in leptin levels with concomitantly occurring changes in cortisol levels, IL-8, and clinical parameters.

DESIGN

Investigative study.

SETTING

University-affiliated tertiary care hospital.

PARTICIPANTS AND INTERVENTIONS

Twenty-nine consecutive patients, aged 6 days to 15 yrs, operated upon for the correction of congenital heart defects were studied. Surgery in 20 patients (group 1) involved conventional CPB techniques, and 9 (group 2) underwent closed-heart surgery. The time courses of leptin, cortisol, and IL-8 levels were determined. Serial blood samples were collected preoperatively, on termination of CPB, and at six time points postoperatively. Plasma was recovered immediately, aliquoted, and frozen at -70 degrees C until use.

MEASUREMENTS AND MAIN RESULTS

The leptin levels in group 1 decreased during CPB to 51% of baseline (p <.001), then gradually increased, reaching 120% of baseline levels at 12-18 hrs postoperatively (p <.001), returning to baseline levels at 24 hrs (p <.01). In patients undergoing closed-heart surgery (group 2), leptin levels displayed a pattern resembling the first group: they decreased during surgery to 71% of baseline levels (p =.002) and showed a tendency to return to baseline thereafter. All group 1 patients' cortisol levels increased significantly during the first hour of surgery, then decreased, returning to baseline levels at 18-24 hrs postoperatively. There was a significant negative correlation between leptin and cortisol levels (r = -2.8, p <.01). In group 2, cortisol levels increased during and after surgery, peaking 4 hrs postoperatively and decreasing thereafter. IL-8 levels determined in 15 group 1 patients increased significantly during CPB, peaked at the end of surgery, and then decreased but remained slightly elevated even at 48 hrs postoperatively. There was a significant correlation between cortisol and IL-8 levels (r = 2.55, p <.05). Children with leukocytosis, tachycardia, and hypotension had lower leptin levels and less variation over time as opposed to those with an uncomplicated course.

CONCLUSIONS

CPB is associated with acute changes in circulating leptin levels. These changes parallel those in cortisol, demonstrating an inverse relationship between leptin and cortisol. Further studies of the prognostic and therapeutic roles of leptin after CPB should be investigated.

Hemodynamic effects of tracheal administration of vasopressin in dogs

BACKGROUND

Intravenous administration of vasopressin during cardiopulmonary resuscitation (CPR) has been shown to be more effective than optimal doses of epinephrine. Earlier studies had been performed on a porcine model, but pigs produce lysine vasopressin hormone, while humans and dogs do not. This study was designed to compare the effects of tracheal vasopressin with those of NaCl 0.9% (placebo) on haemodynamic variables in a dog model.

METHODS

Five dogs were allocated to receive either vasopressin 1.2 U/kg or placebo (10 ml of NaCl 0.9%) via the tracheal route after being anesthetized and ventilated. Haemodynamic variables were determined and arterial blood gases were measured.

RESULTS

All animals of the vasopressin group demonstrated a significant increase of the systolic (from 135+/-7 to 165+/-6 mmHg, P<0.05), diastolic (from 85+/-10 to 110+/-10 mmHg, P<0.05) and mean blood pressure (from 98.5+/-3 to 142.2+/-5, P<0.05). Blood pressure rose rapidly and lasted for more than an hour (plateau effect). Heart rate decreased significantly following vasopressin (from 54+/-9 to 40+/-5 beats per min, P<0.05) but not in the placebo group. These changes were not demonstrated with placebo injection.

CONCLUSION

Tracheal administration of vasopressin was followed by significantly higher diastolic, systolic and mean blood pressures in the vasopressin group compared with the placebo group. Blood gases remained unchanged in both groups. Vasopressin administered via the trachea may be an acceptable alternative for vasopressor administration during CPR, when intravenous access is delayed or not available, however, further investigation is necessary.

Is endotracheal adrenaline deleterious because of the beta adrenergic effect?

IV adrenaline increases coronary and cerebral perfusion pressures during cardiopulmonary resuscitation. We recently showed that endotracheal adrenaline can decrease blood pressure (BP), a detrimental effect presumably mediated by the beta 2-adrenergic receptor unopposed by alpha-adrenergic vasoconstriction. This prospective, randomized, laboratory comparison of endotracheal adrenaline (0.05 mg/kg diluted with normal saline to 10 mL total volume) with or without nonselective beta-blocker (propranolol) pretreatment was conducted in an attempt to clarify the mechanism of this BP decrease. Five mongrel dogs were given 0.05 mg/kg endotracheal adrenaline (diluted) or 0.05 mg/kg endotracheal adrenaline followed by an IV propranolol (0.1 mg/kg) pretreatment. Each dog served as its own control (10 mL of normal saline administered endotracheally) and received each regimen at least one week apart. Endotracheal adrenaline given after the propranolol pretreatment produced an increase in systolic, diastolic, and mean arterial BPs, from 165/110 mm Hg (mean 128 mm Hg) to 177.5/125 mm Hg (mean 142.5 mm Hg), respectively, as opposed to the hypotensive effect of isolated endotracheal adrenaline (P < 0.03). Thus, endotracheal adrenaline was associated with predominantly beta-adrenergic-mediated effects, causing hypotension via peripheral vasodilatation unopposed by alpha-adrenergic vasoconstriction. The search for the optimal dose of endotracheal adrenaline should be aimed at achieving the higher alpha-adrenergic vasoconstrictive threshold.

Soluble P-selectin and the postoperative course following cardiopulmonary bypass in children

BACKGROUND

Cytokine-inducible leucocyte-endothelial adhesion molecules were shown to affect the postoperative inflammatory response following cardiopulmonary bypass (CPB). Soluble P-selectin (sP-selectin) is one of these molecules. We investigated the correlation between plasma sP-selectin levels and the intra- and postoperative course in children undergoing CPB.

METHODS

Serial blood samples of 13 patients were collected preoperatively upon initiation of CPB and seven times postoperatively. Plasma was recovered immediately and frozen at - 70 degrees C until use. Circulating soluble selectin molecules were measured with a sandwich enzyme-linked immunoabsorbent assay technique.

RESULTS

The significant post-CPB changes in sP-selectins plasma levels were associated with patient characteristics, operative variables and postoperative course. sP-selectin levels correlated significantly with surgery time, aortic cross-clamping time and inotropic support, as well as with the postoperative Pediatric Risk of Mortality score, hypotension and tachycardia.

CONCLUSIONS

A relation between CPB-induced mediators and both early and late clinical effects is suggested. The up-regulation and expression of sP-selectin indicate neutrophil activation as a possible mechanism for the increase, and inhibiting it may reduce the inflammatory response associated with CPB.

Beta-chemokine secretion patterns in relation to clinical course and outcome in children after cardiopulmonary bypass: continuing the search to abrogate systemic inflammatory response

BACKGROUND

Surgery involving cardiopulmonary bypass (CPB) is frequently accompanied by a systemic inflammatory response partly triggered by neutrophils and monocyte-macrophages. Certain cytokines that are powerful leukocyte-chemotactic factors have recently been characterized and shown to be important in evoking inflammatory responses: monocyte chemoattractant protein-1 (MCP-1) has monocyte-macrophage chemotactic activity, and regulated-upon-activation normal T-cell expressed and secreted (RANTES) has a potent chemoattractant activity for mononuclear phagocytes. This prospective cohort study investigated possible roles of these chemokines in the inflammatory response to CPB and relationships between the changes in chemokine levels and the clinical course and outcome.

METHODS

Systemic blood of 16 children undergoing CPB was collected after induction of anesthesia (base line); at 15 minutes after bypass onset; at CPB cessation; and at 1, 2, 4, 8, 12, and 24 hours afterward to measure MCP-1 and RANTES.

RESULTS

The significant changes of plasma beta chemokine levels following CPB were associated with patient characteristics, operative variables, and postoperative course. Cardiopulmonary bypass of more than 2 hours, longer surgical times, inotropic support, and reoperation were associated with higher MCP-1 levels and lower RANTES levels.

CONCLUSIONS

Our results suggest a relation between CPB-induced mediators and clinical effects, implying pathogenic roles for chemokines following CPB. These molecules should be considered as possible targets for therapeutic intervention.

Differential regulation of constitutive and retinoic acid-induced galectin-1 gene transcription in murine embryonal carcinoma and myoblastic cells

Galectin-1 (gal-1), a galactoside-binding lectin, is found in many vertebrate tissues and its expression is regulated during development. We had found that gal-1 expression is increased in F9 murine embryonal carcinoma cells concurrently with induction of differentiation by all-trans retinoic acid (RA). In contrast, gal-1 expression was constitutively high in murine myoblastic C2C12 cells. Therefore, we used these two cell types as models to begin to understand the mechanisms underlying constitutive and RA-induced gal-1 expression. We transfected transiently into F9 cells a series of reporter constructs containing different deletions of the 5' upstream region of the gal-1 gene promoter placed upstream of the chloramphenicol acetyltransferase reporter cDNA and evaluated the activation of transcription by RA treatment. The results indicate that the induction of gal-1 by RA is regulated at least partially at the level of transcription. A strong RA responsiveness region was found within the sequence from -1578 to -1448 upstream of the transcription start site (+1). In contrast, the high constitutive gal-1 expression in C2C12 cells appeared to be mediated by a sequence within the promoter region from -62 to +1, which contains an Sp1 consensus sequence. A gel electrophoretic mobility shift assay indicated that the transcription factor SP1 bound to the gal-1 Sp1 site and mutagenesis of this Sp1 site abolished both the binding of nuclear proteins to the mutated Sp1 site and the high constitutive expression of the gal-1 gene. The results demonstrate that gal-1 expression is cell type-specific and suggest that different factors regulate constitutive and RA-induced gal-1 expression.

Overexpression of retinoic acid receptor beta in head and neck squamous cell carcinoma cells increases their sensitivity to retinoid-induced suppression of squamous differentiation by retinoids

Nuclear retinoic acid receptor beta(RARbeta) expression is suppressed in many head and neck squamous cell carcinomas (HNSCCs), and an inverse relationship was found between squamous differentiation and RARbeta expression in such cells. To investigate the role of RARbeta in HNSCC growth and differentiation, we transfected a retroviral RARbeta2 expression vector (LNSbeta) into HNSCC SqCC/Y1 cells, which do not express endogenous RARbeta but do express RARalpha, RARgamma, and retinoid X receptors. Transfected clones expressing RARbeta2 mRNA and protein exhibited enhanced sensitivity to the suppressive effects of all-trans-retinoic acid (ATRA) on squamous differentiation compared with cells transfected with the LNSX vector only; transglutaminase type I level was suppressed after a 3-day treatment with 10(-10) M ATRA in four of five LNSbeta clones, whereas it was not suppressed in LNSX cells even by 10(-6) M ATRA. Similarly, cytokeratin 1 mRNA level was more suppressed in ATRA-treated LNSbeta clones than it was in LNSX cells. This effect was independent of transrepression of activator protein-1. None of the LNSbeta-transfected clones showed an increased growth inhibition by ATRA, 9-cis-retinoic acid, or the synthetic retinoid 6-(5,6,7,8-tetrahydro-5,5,8,8-tetramethyl-2-naphthalenyl)-2-naphthale necarboxylic acid. These findings suggest that, in SqCC/Y1 cells, RARbeta mediates suppression of squamous differentiation by ATRA without enhancing its growth-inhibitory effects.

Atropine pharmacokinetics and pharmacodynamics following endotracheal versus endobronchial administration in dogs

Emergency endotracheal and endobronchial drug administration provide an effective alternative for intravenous drug delivery during cardiopulmonary resuscitation. The purpose of the present study was to determine the immediate pharmacokinetic and pharmacodynamic properties of atropine following administration by either of these routes. Atropine (0.02 mg/kg) was given to seven anaesthetized mongrel dogs. Each dog was studied twice: once when atropine was injected into the endotracheal tube, and on another day when atropine was given via a flexible catheter wedged into a peripheral bronchus. Plasma atropine concentrations and blood gases were measured during 60 min following drug administration. Both routes of atropine administration differed significantly in three measures: the maximal atropine concentration (Cmax) was significantly higher with the endobronchial administration 40.0 +/- 7.8 ng/ml compared to 23.9 +/- 5 ng/ml endotracheally (P = 0.008); atropine's elimination (t1/2beta) half-life was significantly longer with the endobronchial route (39.3 +/- 5.2 min vs. 28.0 +/- 7.9 min; P = 0.05); Endobronchial administration resulted in an increase of 16% in heart rate, beginning immediately after drug delivery and peaking after 5 min. Other pharmacokinetic parameters were not significantly different. We conclude that endobronchial administration of atropine has a clear advantage over the endotracheal route.

Early prediction of neurological outcome after falls in children: metabolic and clinical markers

Falls are the foremost reason for non-fatal injuries and are second only to motor vehicle accidents in causing accidental death. The purpose of this study was to identify the clinical and metabolic predictors of the outcome of head injury caused by falls from a height. Medical records of 61 children who had been admitted to the paediatric intensive care unit from 1990 to 1993 after falling from a height were reviewed retrospectively. Outcomes were categorised as good, moderate, severe, and poor. Glasgow coma scores, pupillary responses, brain oedema, and midline shift are significantly associated with poor outcome (p < 0.05). Metabolic markers associated with poor outcome included hyperglycaemia and hypokalaemia. Children with a poor outcome had, at admission, significantly higher glucose concentrations compared with children with good outcomes (mean SD): 20.0 (7.1) v 9.31 (4.0) mmol/l, p < 0.01), and lower potassium concentrations compared with children with good, moderate, and severe outcomes (mean (SD): 2.8 (0.4) v 3.7 (0.4) mmol/l, p < 0.001, 3.5 (0.3) mmol/l, p < 0.01, and 3.41 (0.3) mmol/l, p < 0.05, respectively). These findings allow for an early allocation of effort and resources to children injured from such falls.

Induction of differentiation and apoptosis in the prostate cancer cell line LNCaP by sodium butyrate and galectin-1

Galectin-1 has been implicated in the process of vertebrate developmental regulation. Sodium butyrate is an established differentiation-inducing agent and has been shown to increase galectin-1 expression in colon carcinoma cells. We studied the roles of butyrate and galectin-1 in the induction of differentiation and apoptosis in the prostate cancer cell line LNCaP. Treatment of LNCaP cells with butyrate resulted in induction of galectin-1 expression in a time- and dose-dependent manner. Treatment with butyrate also resulted in inhibition of proliferation, morphologic changes consistent with a differentiated phenotype, and induction of apoptosis. Prostate specific antigen expression was transiently reduced. To determine which of these effects might be secondary to the induction of galectin-1, LNCaP cells were transfected with a galectin-1 expression vector. The transfected cells displayed growth inhibition and an increased rate of apoptosis. PSA expression was not affected. We conclude that galectin-1 may be responsible for many of the phenotypic changes resulting from butyrate treatment and may function downstream in the pathway of butyrate-induced differentiation. We also found PSA to be somewhat inconsistent as an indicator of differentiation of LNCaP cells, likely due to other factors influencing its expression.