Broad responses and attitudes to having music in surgery (the BRAHMS study) - a South African perspective

BACKGROUND

Music is played in operating theatres (OTs) throughout the world, though controversy around its use exists. While some clinicians may find background music favourable to the theatre mood and a way to augment surgical performance, there is concern raised over its distracting and noise-creating properties.

METHODS

In this prospective observational study, between August and December 2021, 110 surgeons and registrars in South Africa responded to a survey investigating the way they use music, and their perceptions and attitudes towards its effect on the OT environment.

RESULTS

In this cohort, 66% were male, 29% were consultants and the most common age range was 30-39 years old. Eighty per cent of respondents reported that music was played at least "sometimes", with 74% reporting that they enjoyed it. Easy Listening was the most played and preferred genre followed by Top 40/Billboard hits. Overwhelmingly, respondents reported that background music in the OT improved temperament, focus, mood, and performance, though over a quarter felt it worsened communication. Thirty-one per cent of respondents reported that the choice of music depended on the type of operation, and 70% would turn music down or off during crises. Those who enjoyed music in their spare time were significantly more likely to enjoy music in the OT and perceive it positively.

CONCLUSION

This study provides a window into the surgeons' use of and attitudes to intraoperative music in South Africa. While overall, music is viewed positively by this cohort, some concerns remain regarding communication and distractedness. Further interventional and qualitative studies would be useful.

Association between atrial high rate episode burden and autonomic and vascular function in patients with implanted cardiac device

Background

Patients who experience frequent atrial high rate episodes (AHREs), recorded on implantable cardiac devices, are at an increased risk of stroke and systemic embolism. Increased duration of AHRE is related to higher risk of thromboembolic event. The underlying pathophysiology is unclear; however, autonomic and/or endothelial dysfunction may contribute.

Purpose

We tested the hypothesis that patients with high AHRE burden have worse autonomic and vascular function compared to patients with low AHRE burden.

Design

We studied 44 patients split in two groups: high AHRE burden (longest AHRE ≥24 hours; n=22) and low AHRE burden (longest AHRE <24 hours; n=22). Resting time- and frequency-domain measures of HRV were determined to index cardiac autonomic function. High-resolution ultrasound was used to measure brachial artery diameter at rest and during reactive hyperaemia (endothelium-dependent flow mediated dilation (FMD)).

Results

FMD was higher in the low AHRE burden group compared to high AHRE group (5.5% [95% confidence interval (CI):3.4–7.6] vs 3.1% [95% CI: 1.9–6.2]; p=0.04) (table 1). Mean heart rate (p<0.001) and AHRE burden (p=0.02) were independent predictors of FMD on multivariate analysis. Time-domain, frequency-domain and non-linear indices of HRV were not significantly different between the groups. A slower heart rate (Spearman's rho 0.369; p=0.01) and high AHRE burden (Spearman's rho −0.315; p=0.04) were independently associated with changes seen on FMD following adjustment for multiple variables (p=0.001 and p=0.03 respectively).

Conclusion

Endothelium-dependent FMD is impaired in patients with high AHRE burden, while HRV derived indices of autonomic function were not affected by AHRE burden. Endothelial dysfunction may play an important role in the adverse outcomes seen in patients who experience frequent AHRE.

Funding Acknowledgement

Type of funding sources: None.

504 Can Measuring Heart Rate Variability in The Operating Surgeon Provide Insight into Intra-Operative Stress? A Literature Review and Direction for Research

Introduction

Stress affects the internal environment of the operating surgeon. Examining ways to mitigate this could prove important to the health of both surgeon, and patients.

Heart rate variability (HRV) is emerging as a novel, validated measure of autonomic nervous system (ANS) function with developing accessible and non-invasive technologies. HRV parameters correlate to ANS function and can be used to measure responses to various stimuli.

Method

A search strategy was developed to identify 23 articles that matched inclusion criteria. These included data collected intra-operatively with ambulatory monitoring, in simulated settings and one systematic review.

Results

Several studies found increased sympathetic response in the operating surgeon – which correlates with subjective reporting of stress. Some studies compared variables; one study suggested that laparoscopic colorectal surgery caused higher mental strain than open, while another suggested higher stress in surgeons while teaching compared to when primary operator. There have been no comparative trials using HRV in surgeons.

Conclusions

We present a review of the growing literature regarding HRV measurement in surgeons. This novel tool is a promising avenue to provide psychophysiological insight into the operating surgeon. This could guide future research into optimising the theatre environment for intra-operative performance using controlled or in-situ design.

3D-Printed Biodegradable Polymeric Vascular Grafts

Congenital heart defect interventions may benefit from the fabrication of patient-specific vascular grafts because of the wide array of anatomies present in children with cardiovascular defects. 3D printing is used to establish a platform for the production of custom vascular grafts, which are biodegradable, mechanically compatible with vascular tissues, and support neotissue formation and growth.

Contrasting biofunctionalization strategies for the enhanced endothelialization of biodegradable vascular grafts

Surface modification of biodegradable vascular grafts is an important strategy to improve the in situ endothelialization of tissue engineered vascular grafts (TEVGs) and prevent major complications associated with current synthetic grafts. Important strategies for improving endothelialization include increasing endothelial cell mobilization and increased endothelial cell capture through biofunctionalization of TEVGs. The objective of this study was to assess two biofunctionalization strategies for improving endothelialization of biodegradable polyester vascular grafts. These techniques consisted of cross-linking heparin to graft surfaces to immobilize vascular endothelial growth factor (VEGF) or antibodies against CD34 (anti-CD34Ab). To this end, heparin, VEGF, and anti-CD34Ab attachment and quantification assays confirmed the efficacy of the modification strategy. Cell attachment and proliferation on these groups were compared to unmodified grafts in vitro and in vivo. To assess in vivo graft functionality, the grafts were implanted as inferior vena cava interpositional conduits in mice. Modified vascular grafts displayed increased endothelial cell attachment and activity in vivo, according to microscopy techniques, histological results, and eNOS expression. Inner lumen diameter of the modified grafts was also better maintained than controls. Overall, while both functionalized grafts outperformed the unmodified control, grafts modified with anti-CD34Ab appeared to yield the most improved results compared to VEGF-loaded grafts.

Monitoring changes in thioredoxin and over-oxidised peroxiredoxin in response to exercise in humans

INTRODUCTION

Peroxiredoxin (PRDX) and thioredoxin (TRX) are antioxidant proteins that control cellular signalling and redox balance, although their response to exercise is unknown. This study aimed to assess key aspects of the PRDX-TRX redox cycle in response to three different modes of exercise.

METHODS

Healthy males (n = 10, mean ± SD: 22 ± 3 yrs) undertook three exercise trials on separate days: two steady-state cycling trials at moderate (60% [Formula: see text]O2MAX; 27 min, MOD) and high (80% [Formula: see text]O2MAX; 20 min, HIGH) intensities, and a low-volume high-intensity interval training trial (10 × 1 min 90% [Formula: see text]O2MAX, LV-HIIT). Peripheral blood mononuclear cells were assessed for TRX-1 and over-oxidised PRDX (isoforms I-IV) protein expression before, during, and 30 min following exercise (post + 30). The activities of TRX reductase (TRX-R) and the nuclear factor kappa B (NF-κB) p65 subunit were also assessed.

RESULTS

TRX-1 increased during exercise in all trials (MOD, + 84.5%; HIGH, + 64.1%; LV-HIIT, + 205.7%; p < 05), whereas over-oxidised PRDX increased during HIGH only (MOD, - 28.7%; HIGH, + 202.9%; LV-HIIT, - 22.7%; p < .05). TRX-R and NF-κB p65 activity increased during exercise in all trials, with the greatest response in TRX-R activity seen in HIGH (p < 0.05).

DISCUSSION

All trials stimulated a transient increase in TRX-1 protein expression during exercise. Only HIGH induced a transient over-oxidation of PRDX, alongside the greatest change in TRX-R activity. Future studies are needed to clarify the significance of heightened peroxide exposure during continuous high-intensity exercise and the mechanisms of PRDX-regulatory control.

The influence of age and weight status on cardiac autonomic control in healthy children: a review

Heart rate variability (HRV) analyses can provide a non-invasive evaluation of cardiac autonomic activity. How autonomic control normally develops in childhood and how this is affected by obesity remain incompletely understood. In this review we examine the evidence that childhood age and weight status influence autonomic control of the heart as assessed using HRV. Electronic databases (Pubmed, EMBASE and Cochrane Library) were searched for studies examining HRV in healthy children from birth to 18 years who adhered to the Task Force (1996) guidelines. Twenty-four studies met our inclusion criteria. Seven examined childhood age and HRV. A reduction in 24-hour LF:HF was reported from birth to infancy (1 year), while overall HRV (SDNN) showed a marked and progressive increase. From infancy to early-to-late childhood (from 12 months to 15 years) LF:HF ratio was reported to decline further albeit at a slower rate, while RMSSD and SDNN increased. Twenty studies examined the effects of weight status and body composition on HRV. In a majority of studies, obese children exhibited reductions in RMSSD (n = 8/13), pNN50% (n = 7/9) and HF power (n = 14/18), no difference was reported for LF (n = 10/18), while LF:HF ratio was elevated (n = 10/15). HRV changes during childhood are consistent with a marked and progressive increase in cardiac parasympathetic activity relative to sympathetic activity. Obesity disrupts the normal maturation of cardiac autonomic control.

Epizootic neoplasia of the lateral line system of lake trout (Salvelinus namaycush) in New York's Finger Lakes

This article documents an epizootic of inflammation and neoplasia selectively affecting the lateral line system of lake trout (Salvelinus namaycush) in 4 Finger Lakes in New York from 1985 to 1994. We studied more than 100 cases of this disease. Tumors occurred in 8% (5/64) of mature and 21% (3/14) of immature lake trout in the most severely affected lake. Lesions consisted of 1 or more neoplasm(s) in association with lymphocytic inflammation, multifocal erosions, and ulcerations of the epidermis along the lateral line. Lesions progressed from inflammatory to neoplastic, with 2-year-old lake trout showing locally extensive, intense lymphocytic infiltrates; 2- to 3-year-old fish having multiple, variably sized white masses up to 3 mm in diameter; and fish over 5 years old exhibiting 1 or more white, cerebriform masses greater than 1 cm in diameter. Histologic diagnoses of the tumors were predominantly spindle cell sarcomas or benign or malignant peripheral nerve sheath neoplasms, with fewer epitheliomas and carcinomas. Prevalence estimates did not vary significantly between sexes or season. The cause of this epizootic remains unclear. Tumor transmission trials, virus isolation procedures, and ultrastructural study of lesions failed to reveal evidence of a viral etiology. The Finger Lakes in which the disease occurred did not receive substantially more chemical pollution than unaffected lakes in the same chain during the epizootic, making an environmental carcinogen an unlikely primary cause of the epizootic. A hereditary component, however, may have contributed to this syndrome since only fish of the Seneca Lake strain were affected.

Synthesis and properties of photocross-linked poly(propylene fumarate) scaffolds

The photocross-linking of poly(propylene fumarate) (PPF) to form porous scaffolds for bone tissue engineering applications was investigated. PPF was cross-linked using the photoinitiator bis(2,4,6-trimethylbenzoyl) phenylphosphine oxide (BAPO) and exposure to 30 min of long wavelength ultraviolet (UV) light. The porous photocross-linked PPF scaffolds (6.5 mm diameter cylinders) were synthesized by including a NaCl porogen (70, 80, and 90 wt% at cross-linking) prior to photocross-linking. After UV exposure, the samples were placed in water to remove the soluble porogen, revealing the porous PPF scaffold. As porogen leaching has not been used often with cross-linked polymers, and even more rarely with photoinitiated cross-linking, a study of the efficacy of this strategy and the properties of the resulting material was required. Results show that the inclusion of a porogen does not significantly alter the photoinitiation process and the resulting scaffolds are homogeneously cross-linked throughout their diameter. It was also shown that porosity can be generally controlled by porogen content and that scaffolds synthesized with at least 80 wt% porogen possess an interconnected pore structure. Compressive mechanical testing showed scaffold strength to decrease with increasing porogen content. The strongest scaffolds with interconnected pores had an elastic modulus of 2.3+/-0.5 MPa and compressive strength at 1% yield of 0.11+/-0.02 MPa. This work has shown that a photocross-linking/porogen leaching technique is a viable method to form porous scaffolds from photoinitiated materials.

Absent Relative Afferent Pupillary Defect in an Asymptomatic Case of Lateral Chiasmal Syndrome from Cerebral Aneurysm

INTRODUCTION

This report documents a case of an asymptomatic 34-year-old female who had right eye subtle temporal optic nerve pallor with absent clinically detectable relative afferent pupillary defect.

CASE REPORT

This presentation was secondary to a fusiform paraclinoid aneurysm resulting in lateral chiasmal syndrome. Visual fields demonstrated a nasal depression OD. Neuroimaging studies revealed the presence of a fusiform paraclinoid aneurysm compressing the right optic nerve and optic chiasm. The lesion was treated surgically without additional visual loss nor systemic and neurological complications.

CONCLUSIONS

A clinically detectable relative afferent pupillary defect may be absent in unilateral optic nerve pallor and/or visual field loss and does not preclude the need to attempt to identify an underlying etiology. Neuroradiological examination of orbital and cranial structures is an imperative protocol in the appropriate management of this potential life- and vision-threatening condition.

Wintering greater scaup as biomonitors of metal contamination in federal wildlife refuges in the Long Island region

Tissues of greater scaup (Aythya marila mariloides) and components of their habitat (sediment, plankton, macroalgae, and invertebrates) were collected for heavy metal analysis in the winter of 1996-97 from US Department of the Interior wildlife refuges in the Long Island region. Geographic and temporal relationships between the concentration of nine metals in tissue and in habitat components were examined. In greater scaup tissues and habitat components, concentrations of As and Se were highest in Branford, Connecticut; Pb values were greatest in Oyster Bay, New York; and Hg concentrations were largest in Sandy Hook, New Jersey. Over the course of the winter, the concentration of Hg in liver increased, and concentrations of Cd, Cr, Cu, Hg, Pb, Se, and Zn in kidney decreased. Based on several criteria derived from geographic and temporal trends, metals were ranked using the apparent biomonitoring efficacy of greater scaup (As = Cr > Cu = Pb = Zn = Hg > Se = Cd > Ni). Although the seasonal migration and daily mobility of greater scaup are drawbacks to using this species as a sentinel for metal pollution, it was possible to demonstrate a relationship between geographic and temporal patterns of metals in habitat and greater scaup tissue. However, most metal concentrations in tissue were below thresholds known to adversely affect health of waterfowl.

Maternal blood, egg and larval thiamin levels correlate with larval survival in landlocked Atlantic salmon

A link was previously established between the Cayuga syndrome, a condition causing 100% mortality in larval landlocked Atlantic salmon, Salmo salar, in several of New York's Finger Lakes, and a maternal diet of alewife, Alosa pseudoharengus, a non-native thiaminase-rich Clupeid fish. We evaluated salmon larvae viability relative to maternal thiamin status, and investigated the putative link of the Cayuga syndrome to an alewife diet in fish from the geographic regions outside the Finger Lakes/lower Great Lakes watersheds. We identified Cayuga syndrome in Atlantic salmon from Otsego Lake in the Susquehanna River watershed and from Green Pond in New York's Adirondack Mountains. In both systems alewife represent the major component of the diet for the salmon. Thiamin levels in the maternal blood of Otsego salmon with syndrome-negative progeny were three- to four-fold greater than those Otsego females whose progeny exhibited 100% mortality. Thiamin levels in eggs and larvae were directly related to thiamin levels in maternal blood in both syndrome-positive and syndrome-negative stocks. Thiamin bath treatments of syndrome-afflicted larvae eliminated mortality regardless of their lake stock of origin. Maternal blood levels of approximately 0.31 nmol thiamin pyrophosphate/g or 0.44 nmol total thiamin/g appear necessary to achieve egg threshold levels of approximately 0.8 and 1.1 nmol/g unphosphorylated and total thiamin, respectively; these egg thiamin levels should prevent significant syndrome-related mortality in landlocked Atlantic salmon larvae. These results confirm the role of thiamin in the etiology of the Cayuga syndrome and support the dietary link of this naturally occurring thiamin deficiency to the thiaminase-rich alewife.

Factors determining hydrogel permeability

Developing hydrogel membranes and coatings of appropriate permeability characteristics is key to the success of a number bioartificial organ technologies. Key principles relevant to the design and application of hydrogels for such applications were reviewed. The first key point is that permeability is a function of both transport and thermodynamic properties, the diffusion coefficient and partition coefficient, respectively, and that these parameters can be evaluated separately. Although the aspect of partitioning often emphasized is size exclusion, this review points out that many other relevant interactions come into play, especially hydrophobic and electrostatic interactions, and that these phenomena can dominate size exclusion. Similarly, while the diffusion coefficient also is strongly dependent upon size, other interactions can also cause diffusivity to deviate from theories which consider only solute size and gel swelling. For example, the heterogeneity of hydrogel networks can result in permeabilities that fail to decline as much as might be anticipated if networks were uniform.

Aroclors 1254 and 1260 reduce dopamine concentrations in rat striatal slices

Striatal slices from adult male Wistar-derived rats were exposed to a 1:1 mixture of Aroclor 1254:1260 at concentrations in media of 10, 20, 40, 60 or 100 ppm for 6 hr. Following exposure, slices and media were analyzed by high-performance liquid chromatography for dopamine (DA) and its metabolites. PCBs caused a significant dose-dependent decrease in slice DA content at concentrations greater than 20 ppm. Media concentrations of DA and its metabolites were significantly increased by PCB exposure greater than 60 ppm, indicating that, in addition to their suggested role in inhibiting DA synthesis, PCBs may interfere with either vesicular storage or release of DA. These data suggest that in addition to the recognized action of PCBs in inhibiting tyrosine hydroxylase, PCBs may also interfere with the vesicular monoamine transporter, and thereby suggest an additional mechanism by which DA concentrations and metabolism may be altered by PCB exposure.

Quantitation of myocardial dysfunction in ischemic heart disease by echocardiographic endocardial surface mapping: correlation with hemodynamic status

Autopsy studies have suggested that infarction of > 35% of the myocardium is associated with cardiogenic shock. However, the relation between the extent of myocardial dysfunction and hemodynamic status has not been defined in patients in vivo. This study investigated, in patients with short-term and chronic left ventricular dysfunction, the relation between hemodynamic status and the extent of regional dyssynergia measured by two-dimensional echocardiography with quantitative endocardial surface mapping. Sixty patients were classified into hemodynamic groups by pulmonary capillary wedge pressure and cardiac index. Two-dimensional echocardiograms were used to calculate left ventricular endocardial surface area index (ESAi), abnormal wall motion index (AWMi), percentage myocardial dysfunction (%MD), and number of wall motion abnormalities. All patients in class 4 (high pulmonary capillary wedge pressure and low cardiac index had > or = 60% MD. With univariate analysis, hemodynamic class correlated with ESAi, AWMi, %MD, the number of wall motion abnormalities, and two clinical variables (number of infarctions and use of diuretic agents). By stepwise linear regression, only AWMi and the number of infarctions were independently predictive of hemodynamic status.

Intracardiac ultrasound determination of left ventricular volumes: in vitro and in vivo validation

OBJECTIVES

This study was designed to assess the feasibility of calculating left ventricular volumes using intracardiac ultrasound.

BACKGROUND

Previous studies have validated transthoracic echocardiographic determinations of left ventricular volumes and have indicated the superiority of Simpson rule reconstruction algorithms. The feasibility of imaging the left ventricle with intracardiac ultrasound has also been demonstrated.

METHODS

The determination of left ventricular volumes with Simpson rule reconstruction of intracardiac ultrasound images was evaluated in two phases. In vitro validation was performed in 29 animal hearts preserved in either a nondistended or distended state. Latex cast volumes were the reference standard. In vivo studies used 14 pigs, and compared intracardiac ultrasound volumes and ejection fraction with single-plane contrast angiographic values. A 12.5-MHz device was used to record short-axis images at 0.5-cm intervals. These were used to reconstruct the ventricle as a stack of cylindric elements using all imaged levels as well as sections recorded every 1 and 2 cm and at a single midventricular level.

RESULTS

In the in vitro hearts, when all recorded sections were used, there was excellent agreement between intracardiac ultrasound and latex cast volumes (intracardiac ultrasound volume = 0.89 latex cast volume + 2.22, r = 0.95; intracardiac ultrasound volume = 0.97 latex cast volume + 0.91, r = 0.99) for nondistended and distended hearts, respectively. In vivo, there was again close correspondence between ultrasound and angiographic volumes (intracardiac ultrasound volume = 1.04 angiographic volume - 3.6, r = 0.91). The relation between intracardiac ultrasound and angiographic ejection fraction was fair (intracardiac ultrasound ejection fraction = 1.00 angiographic ejection fraction + 6.85, r = 0.69). Excellent correlations for the volumes were maintained as the number of cross sections was reduced to those recorded every 1 and 2 cm (r = 0.87 to 0.99). With a single midventricular site more variable but generally good correlations were obtained (r = 0.77 to 0.99).

CONCLUSIONS

The application of Simpson rule reconstruction to short-axis images of the left ventricle obtained with intracardiac ultrasound provides accurate determination of left ventricular volumes in animal hearts. This technique may prove useful in the analysis of left ventricular structure and function.

Low pressure radiofrequency balloon angioplasty: evaluation in porcine peripheral arteries

OBJECTIVES

The purpose of this study was to evaluate the efficacy of radiofrequency-powered thermal balloon angioplasty in an in vivo porcine model.

BACKGROUND

Various modes of thermal energy used adjunctively during balloon angioplasty have demonstrated the potential to enhance the results of acute lumen dilation.

METHODS

In normal pigs, 75 peripheral arteries were dilated with a newly designed, radiofrequency-powered, thermal angioplasty balloon. All inflations were performed at 2-atm pressure for 85 s. Dilations were performed either with (hot) or without (cold) the application of heat. Lumen dimensions and vessel morphology were assessed with intravascular ultrasonography. At the end of each study, dilated arterial segments were harvested for histologic examination.

RESULTS

Single cold balloon inflations resulted in a 12.7% increase in arterial cross-sectional area whereas single hot inflations resulted in a 22.9% increase (p < 0.03). Similarly, when multiple cold inflations were compared with multiple hot inflations, two, three and four sequential hot inflations resulted in a significantly greater increase in cross-sectional area than an equivalent number of cold inflations (p < 0.03). Histologic examination demonstrated a temperature-dependent effect on the depth of medial necrosis and extent of arterial wall thinning (p < 0.001) as well as evidence for uniform alteration of elastic tissue fibers at temperatures of > or = 60 degrees C (p < 0.03).

CONCLUSIONS

Low pressure radiofrequency thermal balloon angioplasty results in a greater increase in cross-sectional area in porcine peripheral arteries than does nonheated conventional balloon angioplasty. The pathologic basis for this enhanced dilation may be a temperature-dependent effect on medial necrosis, thinning of the arterial wall or alteration of vascular elastic fibers, alone or in combination.

Intracardiac echocardiography in humans using a small-sized (6F), low frequency (12.5 MHz) ultrasound catheter. Methods, imaging planes and clinical experience

OBJECTIVES

This study was designed to determine the clinical utility and feasibility of using 12.5-MHz ultrasound catheters for intracardiac echocardiography.

BACKGROUND

Intracardiac echocardiography is a potentially useful technique of cardiac imaging and monitoring in certain settings. The feasibility of intracardiac echocardiography using 20-MHz ultrasound catheters in patients has been demonstrated. High resolution images of normal cardiac structures as well as cardiac abnormalities have been obtained. However, imaging has been limited by the shallow depth of field inherent in high frequency ultrasound imaging.

METHODS

Intracardiac echocardiography with 12.5-MHz catheters was performed in eight mongrel dogs and 92 patients. Catheters were introduced percutaneously in 80 patients studied in the catheterization laboratory and directly into the heart in 12 patients in the operating room. Right heart imaging was performed in 68 patients and arterial and left heart imaging in 35 patients.

RESULTS

When these catheters were introduced into the venous system, the right atrium, tricuspid valve, right ventricle, pulmonary valve and pulmonary artery were visualized. Pericardial effusion, intracardiac masses and atrial septal defects were correctly identified. The left ventricle, left atrium, mitral valve, aortic valve, aorta and coronary arteries could be imaged from the arterial circulation. Diseases identified included valvular aortic stenosis, subvalvular aortic stenosis and Kawasaki disease. Average imaging time was 10 min. No complications occurred as a result of intracardiac echocardiography.

CONCLUSIONS

Intracardiac echocardiography with 12.5-MHz ultrasound catheters is safe and feasible; it also provides anatomic and physiologic information. This feasibility study provides a foundation for wider clinical use of intracardic echocardiography.

Factors influencing the differentiation of embryonal carcinoma and embryo-derived stem cells

The effects of aggregation, retinoic acid, and medium conditioned by Buffalo rat liver (BRL) cells, alone and in combination, on the differentiation of PSA4TG12 embryonal carcinoma and E14 embryonal stem cells are reported. The observations indicate that BRL-conditioned medium has more than one effect on the differentiation process, that retinoic acid has at least two effects which operate in different concentration ranges, and that both agents influence the choice of differentiation pathway as well as the extent of differentiation.

Drug-induced left ventricular failure in patients with pulmonary disease. Endomyocardial biopsy demonstration of catecholamine myocarditis

Three patients with severe chronic lung disease had left ventricular failure develop with marked impairment of cardiac function. Ejection fractions by radioactive blood pool ventriculography were 0.17, 0.24, and 0.20. Right ventricular endomyocardial biopsy specimens showed interstitial hemorrhage and foci of interstitial polymorphonuclear leukocytes, strongly suggestive of catecholamine myocarditis. These patients had used beta-adrenergic agonist inhalants and methylxanthines. One of them clearly abused the inhalant and had elevated levels of urinary catecholamines. Progressive deterioration of pulmonary and cardiac function occurred in two patients, with death within three months of the initial myocardial biopsy. Concomitant use of beta-adrenergic agonists and methylxanthines may cause myocarditis with left ventricular failure in susceptible patients.

The acute retinal necrosis syndrome. Part 1: Clinical manifestations

The acute retinal necrosis syndrome is characterized by necrotizing retinitis, vitritis, and retinal vasculitis occurring in otherwise healthy patients. Experience with 11 cases and the review of 30 additional cases in the literature are presented. In this series, 50% of the affected eyes developed retinal detachments, and 64% had a final visual acuity of less than 20/200. The natural history, diagnosis, postulated etiology, and suggestions for management will be discussed.

Toxicity, efficacy, and clearance of intravitreally injected of cefazolin

The intravitreal injection of cefazolin sodium was evaluated with respect to its potential toxicity, efficacy, and clearance in the treatment of bacterial endophthalmitis in the rabbit model. Toxicity evaluation included indirect ophthalmoscopy, scotopic electroretinogram, and light microscopy of histopathologic specimens. Rabbits given doses up to and including 2.25 mg of cefazolin sodium showed no evidence of toxic reaction by these criteria after two weeks of observation. When injected within 24 hours of inoculation, 2.25 mg of cefazolin sodium sterilized five of six rabbit eyes infected with Staphylococcus aureus. Following intravitreal injection of 2.25 mg of cefazolin sodium, vitreous concentrations in excess of the minimum inhibitory concentration for S aureus were maintained for five days. A 2.25-mg dose of cefazolin sodium appears to be nontoxic, effective, and biologically active against susceptible organisms during a prolonged period, when injected into the vitreous cavity of the pigmented rabbit in vivo.