Risk control of surgical site infection after cardiothoracic surgery.

The purpose of this prospective study was to investigate whether a risk control programme based on risk assessment, new treatment modalities and the presence of a surveillance programme reduces the incidence of surgical site infections (SSI). Between January 2001 and December 2003, 167 patients were treated for a total of 183 SSIs. Data were collected on pre-operative risk factors, intra-operative data and postoperative recovery, including complications, infecting organisms, SSI treatment techniques and length of hospital stay. In this series, the total incidence of SSI was 5.6%. The mean age of affected patients was 65.1 years with a range of 20-87 years. Mean intensive care and hospital stay for SSI was 3.6 days and 18.8 days, respectively. Total mortality was 4.8%. Many risk factors were encountered, some of which were associated with a high morbidity. The majority of SSIs were treated by topical negative pressure therapy (N=81), which gave few side-effects and good clinical results. After starting the surveillance programme, a steady decline in prevalence was observed from 8.9% to 3.9%. This series adds to the evidence that SSI after cardiothoracic surgery is a major but mainly preventable cause of morbidity and mortality. Risk factor assessment, application of novel treatment modalities and an adequate surveillance system all increased patient safety.

Pharmacokinetics of 5-fluorouracil assessed with a sensitive mass spectrometric method in patients on a dose escalation schedule.

The pharmacokinetics of 5-fluorouracil (5-FUra) was investigated in 21 patients with advanced cancer (mainly colorectal cancer). 5-FUra was administered as weekly i.v. bolus injections usually at a starting dose of 500 mg/m2. Every 4 weeks the dose was escalated by 20% until dose-limiting toxicity was observed. Whenever possible, pharmacokinetic studies were performed at dose escalation. 5-FUra plasma concentrations were measured by high pressure liquid chromatography and a sensitive gas chromatography-mass spectrometry assay with a sensitivity as low as 3 x 10(-9) M. According to the 42 plasma concentration versus time curves, in all but one of the patients total body clearance decreased with increasing 5-FUra doses, consistent with the nonlinear pharmacokinetics of 5-FUra. The ultrasensitive assay revealed an almost horizontal phase in the plasma concentration versus time curves at plasma concentrations of 10(-8) to 10(-9) M. This plateau did not show correlation with the area under those curves. The use of a logistic regression method showed that clinical toxicity was correlated with the area under the plasma concentration versus time curve of 5-FUra.

Ultraviolet photoelectron spectroscopy of cyclic amidines. 2. Electronic structure of clonidine and some related 2-(phenylimino)imidazolidines with alpha-adrenergic activity.

Ultraviolet photoelectron spectroscopy (UV PES) and CNDO/s molecular orbital calculations have been employed to investigate the electronic structure of clonidine and some other 2-(phenylimino)imidazolidines. The assignment of the bands in the spectra to particular molecular orbitals is based on the CNDO/s results in conjunction with Koopmans' theorem, substituent effects, and differences in intensity between the He (I) and He(II) spectra. The location of the energy levels of orbitals with mainly nN and delta character is not correctly estimated estimated by CNDO/s, while the pi orbital energy levels are satisfactorally predicted. The UV PES and CNDO/s results indicate in contrast investigated 2-(phenylimino)imidazolidines, which may indicate that differences in hypotensive activity cannot be ascribed to variations in steric hindrance within the molecules. The first ionization energies of the pharmacologically active 20-(phenylimino)imidazolidines do not correlate with hypotensive activity based on dosage data after intravenous administration to rats.

Conformational requirements for norepinephrine uptake inhibition by phenethylamines in brain synaptosomes. Effects of alpha-alkyl substitution.

Amphetamine is a strong competitive antagonist of brain synaptosomal [3H]norepinephrine ([3H]NE) uptake. Its alpha-ethyl analogue is much less active, while 2-aminotetralin and 1,2-dihydro-2-aminonaphthalene, in which the alpha-ethyl group is tied to the aromatic ring, possess about the same inhibitory potency as amphetamine. The conformational properties of these compounds in solution were studied by 1H and 13C NMR methods. Only small differences between amphetamine and alpha-ethylphenethylamine hydrochlorides were observed in the relative rotamer populations due to rotation around the C alpha -C beta bond of the side chain. In D2O the gauche conformation is slightly favored, while in CDCl3 the trans conformation is the predominant one. Conformational analysis of the alpha-ethyl group in alpha-ethylphenethylamine showed that this group exists in two equally populated conformations in both solvents. It is suggested that these conformations hinder the approach of alpha-ethylphenethylamine to the brain synaptosomal NE uptake sites.

Comparison of transthoracic and transesophageal color Doppler flow imaging in patients with mechanical prostheses in the mitral valve position.

This study determined the relative value of transthoracic and transesophageal color Doppler flow imaging to systolic flow patterns in the left atrium in different types of mechanical prostheses in the mitral valve. Thirty-nine patients were investigated. Based on clinical findings, 36 of 39 patients had normal prosthetic valve function. Seventeen patients were interrogated within a few days after surgery. Systolic regurgitant jets in the left atrium were absent in all patients by both transthoracic pulsed and color Doppler flow imaging. Using transthoracic continuous wave Doppler, however, jets were demonstrated in 8 of 39 patients (21%). Transesophageal color Doppler flow imaging demonstrated systolic regurgitant jets originating from the prosthesis in all patients. Tilting disc valves showed jets during the entire systole (closure and leakage backflow). Each type of prosthesis generated a specific jet pattern. Pathologic regurgitant jets were crescent-shaped, more extensive and turbulent than jets caused by normal closure and leakage backflow. Thus, transthoracic color Doppler flow imaging is not sensitive for detecting regurgitant jets in mechanical prostheses in the mitral valve. All mechanical prostheses show a specific jet pattern, which should be helpful when transesophageal echocardiography is used to identify pathologic backflow.

Sheathless preconcentration-capillary zone electrophoresis-mass spectrometry applied to peptide analysis.

A reliable capillary zone electrophoresis-electrospray ionization-tandem mass spectrometry system has been developed for the sensitive analysis and sequencing of peptides. The system comprises (1) a zero dead volume on-line sample preconcentration interface allowing over 100-fold increase in sample volume introduction and (2) a zero-dead volume, durable electrospray emitter yielding stable, low background electrospray signals, both proving not to compromize the electrophoretic performance. Sub-fmol sensitivities were obtained in applications to complex peptide samples derived from tryptic digestion of proteins and naturally processed major histocompatibility complex class I associated peptides.

Isolation, identification and immunosuppressive activity of a new IMM-125 metabolite from human liver microsomes. Identification of its cyclophilin A-IMM-125 metabolite complex by nanospray tandem mass spectrometry.

The isolation from human liver microsomes and identification by electrospray mass spectrometry and tandem mass spectrometry of a new metabolite of IMM-125 resulting from the biotransformation of the amino acid 1 vinylic methyl group to a carboxylic acid, called the IMM-125-COOH metabolite, is described. It was found that the complex of this new metabolite with cyclophilin A is formed less easily than the corresponding cyclophilin A-IMM-125-CH2OH main metabolite and cyclophilin A-IMM-125 complexes. However, when formed, the IMM-125-COOH metabolite-cyclophilin A complex requires more collision-induced dissociation (CID) to dissociate the complex than the complexes formed with the two other ligands. The nanospray tandem mass spectrum of the IMM-125-COOH metabolite-cyclophilin A complex (m/z 1755) gives rise to cyclophilin A-ligand complexes of m/z 1751 by elimination of CO2 and of m/z 1749 by loss of CO2 and H2O or glycerol. Since immunosuppressive activity is known to be dependent on the formation of a binary complex between cyclophilin A and the drug and since the target for the binary complex was found to be the calcium- and calmodulin-dependent protein phosphatase, calcineurin, it could be interesting to measure for structurally related immunosuppressive drugs the CID energy necessary to dissociate the binary complexes in order to evaluate whether a correlation with the phosphatase activity could be derived.

Relationships between structure and alpha-adrenergic receptor affinity of clonidine and some related cyclic amidines.

The inhibition of specific [3H]clonidine binding to alpha-adrenergic receptors in rat brain has been studied for 43 compounds structurally related to clonidine. Oxymetazoline was found to be the most potent compound in displacing [3H]clonidine from its binding sites. 2-Methylimidazoline, 1,2,3,5-tetrahydroimidazo[2,1-b]quinazoline and heterocyclic N-methyl-substituted compounds showed no affinity at all for [3H]clonidine receptor sites. There was a good correlation between hypotensive activity and alpha 2-adrenergic receptor affinity to some 2-(phenylamino)imidazolidines. Parallelisms between Ki's and pharmacological activities were also observed for other compounds. Apparent structural requirements for alpha 2-receptor affinity were the presence of an aromatic moiety and a N-hydrogen in the heterocyclic ring. Ortho substitution in the phenyl ring was necessary for high affinity. Compounds with an oxazolidine ring had approximately similar affinities for the [3H]clonidine binding sites compared with the corresponding imidazolines (except for the 2,6-dichlorophenyl-substituted compound) whereas the pyrrolidine derivatives showed a 10-fold weaker affinity. [3H]Clonidine sites showed a homogeneous character. KD values from saturation and displacement experiments were in good agreement with one another (2.6 and 2.7 nM, respectively) and with values in the literature.

Structure activity correlations in the inhibition of brain synaptosomal 3H-norepinephrine uptake by phenethylamine analogs. The role of alpha-alkyl side chain and methoxyl ring substitutions.

alpha-Ethylphenethylamine proved to be a weaker inhibitor of rat brain synaptosomal [3H]norepinephrine ([3H]NE) uptake than amphetamine, while 2-amino-tetralin and 2-amino-1,2-dihydronaphtalene, compounds in which the alpha-side chain ethyl group is tied to the aromatic ring have a similar inhibiting potency as amphetamine. Hallucinogenic polymethoxy substituted phenethylamine analogs have very low inhibitory potencies indicating that inhibition of NE-reuptake in brain noradrenergic neurons is not associated with the drug-induced hallucinogenic syndrome.

Determination of sorbitol in erythrocytes of diabetic and healthy subjects by capillary gas chromatography.

A gas-liquid chromatographic method, using a fused silica capillary column, for the determination of red cell sorbitol is described. The capillary column gives complete resolution of the polyols xylitol, inositol, mannitol, sorbitol and galactitol, even when the glucose peak in the red cell chromatogram is dominating. The identity of sorbitol, and its single elution from the capillary column has been confirmed by mass spectrometry. Recovery of sorbitol from various red cell samples was 101% +/- 3.2 (mean +/- SD, n = 7). Precision, estimated from duplicate diabetic red cell sorbitol analyses was CVdup = 3.5% (n = 18) and from run to run analyses CVinterassay = 4.0% (n = 6). Sorbitol levels determined in erythrocytes of 19 healthy subjects were 5.9 +/- 1.6 nmol/ml red cells and in erythrocytes of 18 insulin-dependent diabetics 17.8 +/- 8.2 nmol/ml red cells (means +/- SD). The method described offers a reliable and specific tool to study in vivo polyol pathway activity in relation to some diabetes-associated complications.

A new method for the determination of L-dopa and 3-O-methyldopa in plasma and cerebrospinal fluid using gas chromatography and electron capture negative ion mass spectrometry.

L-3-(3,4-Dihydroxyphenyl)alanine (DOPA) and its 3-O-methyl metabolite (OMD) were measured in plasma and cerebrospinal fluid by a new assay which combines N,O-acetylation of amino acids in aqueous media, preparation of pentafluorobenzyl esters under anhydrous conditions, and analysis by gas chromatography-electron capture negative ion mass spectrometry. The N,O-acetyl, carboxy-PFB derivatives gave abundant carboxylate anions ([M-CH2C6F5]-) which were suitable for sensitive analysis using selected ion monitoring. Plasma and CSF samples were sufficiently purified by a simple organic solvent extraction. Analytical recovery for DOPA was 100.2 +/- 3.7% at the level of 100 nmol/l. Analysis of DOPA in plasma was performed with a relative standard deviation of 5%. The limit of quantitation in plasma and CSF was at the sub-nmol/l level. In healthy adults, DOPA concentration in plasma was 9.0 +/- 2 nmol/l (n = 11) and in CSF 3.5 +/- 0.9 nmol/l (n = 9). The concentration of OMD in plasma was 99.1 nmol/l (pool of 24 samples) and 15.3 nmol/l in CSF (pool of 12 samples). Measurement of 5-[2H]DOPA and 5-[2H]OMD in plasma of a healthy individual who had been orally loaded with 3,5-[2H2]tyrosine (150 mg kg body wt) was possible for several hours after the load.

Stable isotope dilution analysis of succinylacetone using electron capture negative ion mass fragmentography: an accurate approach to the pre- and neonatal diagnosis of hereditary tyrosinemia type I.

A sensitive and accurate isotope dilution assay using electron capture negative ion mass fragmentography was developed for succinylacetone in amniotic fluid, plasma and urine. The method utilizes (D4)-5(3)-methyl-3(5)-isoxasole propionic acid as internal standard. Sample pretreatment consisted of oximation at pH less than 2 to 5(3)-methyl-3(5)-isoxasole propionic acid, clean up using liquid partition chromatography and further derivatization to the pentafluorobenzyl ester. Control values in plasma revealed a mean means = 0.044 mumol/l, range = 0.005-0.163 mumol/l, in urine means = 0.15 mumol/l, range 0.01-0.40 mumol/l corresponding to means = 0.03 mumol/mmol creat., range 0.01-0.14 mumol/mmol creat., and in amniotic fluid means = 0.016 mumol/l, range = 0.001-0.030 mumol/l. The utility of the method was demonstrated by quantification of succinylacetone in urine from patients with hereditary tyrosinemia type I (n = 8, excretion range 2.60-493.3 mumol/l corresponding to 0.67-197.3 mumol/mmol creat.) and in two amniotic fluid samples from fetuses affected with this disorder (concentration of succinylacetone 0.085 and 1.50 mumol/l, respectively). Maternal urine from a woman carrying an affected fetus did not show elevated urinary succinylacetone excretion.

Stable isotope dilution analysis of pipecolic acid in cerebrospinal fluid, plasma, urine and amniotic fluid using electron capture negative ion mass fragmentography.

A sensitive and accurate stable isotope dilution assay was developed for the measurement of pipecolic acid in body fluids using electron capture negative ion mass fragmentography. The method utilizes [2H11]pipecolic acid as the internal standard. Sample preparation consisted of derivatization in aqueous solution (pH 11.5) of the amine moiety with methyl chloroformate to the N-methylcarbamate, followed by acidic ethyl acetate extraction (pH 2) and further derivatization of the carboxyl moiety to the pentafluorobenzyl ester. Normal values have been determined in cerebrospinal fluid (mean means = 0.041 mumol/l, range 0.010-0.120 mumol/l), in plasma of at term infants (age less than 1 wk, means = 5.73 mumol/l, range 3.75-10.8 mumol/l; age greater than 1 wk, means = 1.46 mumol/l, range 0.70-2.46 mumol/l), in urine of at term infants (age less than 6 mth, means = 32.5 mumol/g. creat., range 9.81-84.5 mumol/g. creat; age greater than 6 mth, means = 6.35 mumol/g. creat., range 0.15-13.6 mumol/g. creat.) and in amniotic fluid (means = 4.65 mumol/l, range 2.24-8.40 mumol/l). The utility of the method was demonstrated for the pipecolic acid quantification in these biofluids of patients with peroxisomal disorders. As affected fetuses with infantile Refsum's disease and Zellweger syndrome showed no significant elevation of pipecolic acid in their surrounding amniotic fluids, the measurement of pipecolic acid in amniotic fluid seemed not to be useful for prenatal diagnosis in these disorders.

Enzyme amplification as detection tool in continuous-flow systems. I. Development of an enzyme-amplified biochemical detection system coupled on-line to flow-injection analysis.

The on-line coupling of flow-injection analysis (FIA) to an enzyme-amplified biochemical detection (EA-BCD) system is described. The aim of this study is the development of a detection system able to detect biotin-containing compounds at low concentration levels. The detection system is based on the interaction of biotin with enzyme-labeled affinity proteins. Biotin possesses a high affinity to both streptavidin and anti-biotin Fab fragments, which are both tested. Several biotin derivatives are available with different reactive probes, which can be used to label analytes of interest. Therefore, biotin acts as a universal probe for the enzyme-amplified biochemical detection. Alkaline phosphatase (AP) was used as enzyme label. Several parameters, such as substrate type and concentration, concentration of enzyme-labeled affinity protein, reaction time and reaction temperature were examined. Biotin aminocaproic acid was used as a model compound. In addition to biotin aminocaproic hydrazide, other biotinylation reagents were also examined. With fluorescence detection of the enzyme-generated product, a mass detection limit of 1 fmol was achieved.

Enzyme amplification as detection tool in continuous-flow systems. II. On-line coupling of liquid chromatography to enzyme-amplified biochemical detection after pre-column derivatization with biotin.

Enzyme-amplified biochemical detection (EA-BCD) was used as a post-column detection technique, coupled on-line with high-performance liquid chromatography (HPLC). The enzyme detection system was developed to detect biotin or biotin containing compounds. Biotinylation is widely used to label analytes of interest ranging from small molecules to proteins and DNA. Naphthalene aldehyde and anthracene aldehyde were used as model compounds. Both compounds were biotinylated off-line with biotin aminocaproic hydrazide (BACH). On-column biotinylation was performed by preconcentration of anthracene aldehyde on copper phthalocyanine. After biotinylation, samples were introduced to the HPLC system. Enzyme-labeled streptavidin, which possesses high affinity to biotin, was added post-column to the HPLC effluent. Excess of enzyme-labeled affinity protein was removed by means of an immobilized biotin column. After separation of free and bound fraction, substrate was added, which was converted to a fluorescent product by the enzyme label. Using alkaline phosphatase as an enzyme label, a mass detection limit after on-column preconcentration and biotinylation of 250 fmol was achieved.

Screening and analysis of polar pesticides in environmental monitoring programmes by coupled-column liquid chromatography and gas chromatography-mass spectrometry.

Screening and analysis of polar pesticides based on coupled-column reversed-phase liquid chromatography (LC-LC) and GC- or LC-MS is a powerful tool in the execution of environmental monitoring programmes. This paper presents a unified approach utilising LC-LC screening followed by GC-MS confirmation. As polar pesticides are not generally amenable to GC a widely applicable derivation technique is used. The results demonstrate that the proposed LC and MS techniques are capable of analysing a wide range of polar pesticides down to levels of 0.1 microgram/l (EU limit for drinking water). LC switching techniques for group analysis or individual compounds rely on the reversed-phase retention and the UV detectability of the pesticides in combination with the choice of the LC columns. Fast miniaturised derivatization prior to GC-MS forms an integral part in the proposed strategy. In order to avoid extraction losses, derivation in the aqueous sample, preferably with electrophoric reagents with enhanced sensitivity in GC-NICI-MS are employed where possible. In this communication, method development and validation fitting in the strategy are evaluated and the results of the combined approach are discussed.

High-performance liquid chromatography coupled to enzyme-amplified biochemical detection for the analysis of hemoglobin after pre-column biotinylation.

The determination of proteins with enzyme-amplified biochemical detection (EA-BCD) coupled on-line with high-performance liquid chromatography (HPLC) is demonstrated. The EA-BCD system was developed to detect biotin-containing compounds. Hemoglobin, which was used as a model compound, was biotinylated prior to sample introduction. Several biotinylation parameters, such as pH and removal of excess biotinylation reagent, were investigated. After biotinylation samples were introduced to HPLC followed by EA-BCD. To the HPLC effluent, alkaline phosphatase label streptavidin (S-AP) was added, which possesses high affinity to biotin and biotin-containing compounds. Excess S-AP was removed by means of an immobilized biotin column followed by substrate addition. The non-fluorescent substrate is converted to a highly fluorescent product by the enzyme label. A detection limit of 2 femtomol biotinylated Hb was achieved with good reproducibility and linearity. However, biotinylation at low analyte concentration suffers from low yield due to slow reaction kinetics. Finally, Hb was successfully extracted from urine with a recovery of 94%.

Modified sampling and analysis method for large volatility range airborne polycyclic aromatic hydrocarbons (PAH) using gas chromatography-mass spectrometry.

A sampling method has been developed for the measurement for polycyclic aromatic hydrocarbons in ambient air by gas chromatography isotope dilution mass spectrometry. The method has been designed to measure the largest possible volatility range of PAHs including the abundant naphthalenes. Sample volumes were approx. 500 m(3) in size at a sampling rate of approx. 18 m(3)/h. The sampler contained three sorption stages for the simultaneous capturing of particle bound and low and high volatile gaseous PAH, respectivley. Recoveries of sampling spikes were on average 90%. The detection limit was approx. 5 pg/m(3) for the high boiling range PAH. Results obtained showed a quite steady profile for most PAH in background air in The Netherlands. Comparison of abundance ratios with literature data indicate that traffic exhausts are the major source for the PAH in the area.

Clinical evaluation of Duraflo II heparin treated extracorporeal circulation circuits (2nd version). The European Working Group on heparin coated extracorporeal circulation circuits.

OBJECTIVES: To evaluate whether the application of heparin treated circuits for elective coronary artery surgery improves postoperative recovery, a European multicenter randomised clinical trial was carried out. METHODS: In 11 European heart centers, 805 low-risk patients underwent cardiopulmonary bypass (CPB) with either an untreated circuit (n = 407) or an identical but heparin treated circuit (n = 398, Duraflo II). RESULTS: Significant differences were found among participating centers with respect to patient characteristics, blood handling procedures and postoperative care. The use of heparin treated circuits revealed no overall changes in blood loss, blood use, time on ventilator, occurrence of adverse events, morbidity, mortality, and intensive care stay. These results did not change after adjustment for centers and (other) prognostic factors as analysed with logistic regression. In both groups no clinical or technical (patient or device related) side effects were reported. Because female gender and aortic cross clamp time appeared as prognostic factors in the logistic regression analysis, a subgroup analysis with these variables was performed. In a subpopulation of females (n = 99), those receiving heparin treated circuits needed less blood products, had a lower incidence of rhythm disturbances and were extubated earlier than controls. In another subgroup of patients with aortic cross clamp time exceeding 60 min (n = 197), the amount of patients requiring prolonged intensive care treatment (> 24 h) was significantly lower when they received heparin treated circuits versus controls. CONCLUSION: These findings suggest that improved recovery can be expected with heparin treated circuits in specific higher risk patient populations (e.g. females) and when prolonged aortic cross clamp time is anticipated. Further investigations are recommended to analyses the clinical benefit of heparin treated circuits in studies with patients in different well defined risk categories and under better standardised circumstances.

Congener-specific bioavailability of PCDD/Fs and coplanar PCBs in cows: laboratory and field measurements.

To estimate congener-specific bioavailabilities for 17 PCDD/Fs in cows grazing near a MSW incinerator both a controlled lab study and a field study were performed. In the lab study the estimates were derived from the elevated concentrations in milk from two cows after administration of a single dose of contaminated fly ash. In the field study, located near a large MSW incinerator, daily samples of grass and milk collected over a period of 60 days were pooled to two monthly bulk samples. The concentrations in these bulk samples of grass and milk were used to estimate the bioavailabilities of the 17 PCDD/Fs as well as of three coplanar PCBs. With the concentrations of PCDD/Fs expressed in I-TEQs the bioavailability in cows was estimated at +/- 7.5% in the field study. The congener-specific bioavailabilities correlated well between the two studies, as well as with previously reported values in the literature. However, the absolute levels differed considerably between studies, indicating a strong matrix effect.