A web-based pedometer programme in women with a recent history of gestational diabetes.

AIMS: Women with remote histories of gestational diabetes mellitus can reduce their diabetes risk through lifestyle changes, but the effectiveness of interventions in women with more recent histories of gestational diabetes has not been reported. Therefore, we conducted a pilot study of a low-intensity web-based pedometer programme targeting glucose intolerance among women with recent gestational diabetes. METHODS: Women with a gestational diabetes delivery within the past 3 years were randomized to a 13-week intervention consisting of a structured web-based pedometer programme which gave personalized steps-per-week goals, pedometers and education regarding lifestyle modification, or to a letter about diabetes risk reduction and screening after delivery for gestational diabetes (control condition). The main outcome measures were change in fasting plasma glucose and 2-h glucose levels on a 75-g oral glucose tolerance test between baseline and 13-week follow-up. Weight was a secondary outcome and behavioural constructs (self-efficacy, social support, risk perception) were also assessed. RESULTS: Forty-nine women were enrolled. At 13-week follow-up, women randomized to the intervention did not have significant changes in behavioural constructs, physical activity or anthropometrics compared with women in the control group. Changes in fasting plasma glucose (-0.046 mmol/l vs. 0.038 mmol/l, P = 0.65), 2-h glucose values (-0.48 mmol/l vs. -0.42 mmol/l, P = 0.91) and weight (-0.14 kg vs. -1.5 kg, P = 0.13) were similar between the control and intervention groups, respectively. CONCLUSIONS: Structured web-based education utilizing pedometers is feasible although uptake may be low. Such programmes may need to be supplemented with additional measures in order to be effective for reduction of diabetes risk.

Survey of the prevalence of Salmonella species on laying hen farms in Kosovo.

A survey on the prevalence of Salmonella (S) species was carried out on 39 layer farms in Kosovo between April and September 2012. In total 367 samples, comprising feces, dust, eggs, and internal organs from dead birds, were investigated using bacteriological culture methods. Additionally, data on the location of the farm, the total number of birds on the farm, age of birds, and laying performance were collected. Salmonella were isolated from 38 samples obtained from 19 (49%) farms. The most common serovar identified was Salmonella enteritidis, found on 18 farms. The most common S. enteritidis phage type was PT29 followed by PT6, PT7, PT21, PT13a, PT8, PT14b, and PT4. One S. enteritidis isolate was not typable. Six farms had more than one phage type. Furthermore, serovar S. Bovismorbificans also was found in samples from 3 farms. Flock size or production stage was not associated with the probability of isolating Salmonella. The only flock factor found to be significantly associated was percent hen/day production: It was 2.8 times more likely to isolate Salmonella from flocks with production above 80% hen/day production compared to flocks producing at a lower level. Analysis of antimicrobial resistance patterns of 30 isolates revealed that all isolates were sensitive to gentamicin, ampicillin, sulphamethoxazole trimethoprim, and oxytetracycline, and 29 (97%) were sensitive to ciprofloxacin. All isolates showed intermediate resistance or were resistant to minocycline and cloxacillin. Twenty-six isolates (86%) had intermediate resistance to amoxicillin and 27 isolates (90%) were fully resistant to streptomycin. The present survey revealed a high prevalence of Salmonella enteritidis in layer flocks in Kosovo, indicating that table eggs have to be suspected as an important source of human salmone-llosis.

Stimulated human neutrophils damage cardiac sarcoplasmic reticulum function by generation of oxidants.

An important aspect of myocardial injury is the role of neutrophils in post-ischemic damage to the heart. Stimulated neutrophils initiate a series of reactions that produce toxic oxidizing agents. Superoxide rapidly dismutases to H2O2 and neutrophils contain myeloperoxidase which catalyzes the oxidation of Cl- by H2O2 to yield hypochlorous acid (HOCl). The highly reactive HOCl combines non-enzymatically with nitrogenous compounds to generate long-lived, non-radical oxidants, monochloramine and taurine N-monochloramine. We investigated the role of oxygen radicals and long-lived oxidants on cardiac sarcoplasmic reticulum function, which plays a major role in the regulation of intracellular Ca2+ and thereby in the generation of force. Incubation of sarcoplasmic reticulum with phorbol myristate acetate (PMA)-stimulated neutrophils (4 x 10(6) cells/ml) significantly decreased calcium uptake rate (0.85 +/- 0.11 to 0.11 +/- 0.06 mumol/min per mg) and Ca2+-ATPase activity (1.67 +/- 0.08 to 0.46 +/- 0.10 mumol/min per mg). Inclusion of myeloperoxidase inhibitors (cyanide, sodium azide and 3-amino-1,2,4-triazole), catalase, superoxide dismutase plus catalase, and alpha-tocopherol significantly protected (P less than 0.01) calcium uptake rates and Ca2+-ATPase activity of sarcoplasmic reticulum. Superoxide dismutase (10 microgram/ml) alone or deferoxamine (1 mM) had no protective effect in this system. The maximum inhibition of sarcoplasmic reticulum function was observed with (3-4) x 10(6) cells/ml in 4-6 min. HOCl and NH2Cl inhibited calcium uptake rate and Ca2+-ATPase activity of sarcoplasmic reticulum in a dose-dependent manner (2-20 microM), whereas H2O2 damaged sarcoplasmic reticulum at concentrations ranging from 5 to 25 mM. HOCl (20 microM) inhibited 80-90% of Ca2+-uptake rate and Ca2+-ATPase activity and L-methionine (0.1-1 mM) provided complete protection. We conclude that stimulated neutrophils damage cardiac sarcoplasmic function by generation of myeloperoxidase-catalyzed oxidants.

Essential role of inducible nitric oxide synthase in monophosphoryl lipid A-induced late cardioprotection: evidence from pharmacological inhibition and gene knockout mice.

BACKGROUND: Monophosphoryl lipid A (MLA), a nontoxic analogue of endotoxin, is a pharmacological agent that is known to have anti-ischemic effects. Mechanisms involved with the cardioprotection are still unclear. A role for inducible nitric oxide synthase (iNOS) was recently proposed. We tested this hypothesis using S-methylisothiourea (SMT), one of the specific pharmacological inhibitors of iNOS, as well as iNOS gene knockout mice. METHODS AND RESULTS: Adult male ICR or B6,129 mice were pretreated with either MLA 35 or 350 microg/kg IP (MLA35 or MLA350) or vehicle 24 hours before global ischemia/reperfusion, which was carried out in a Langendorff isolated perfused heart model (n=8 to 9 per group). Another group of MLA350 mice received SMT 3 mg/kg IP 30 minutes before heart perfusion. Ventricular contractile function and heart rate were not different between the groups during the preischemia and reperfusion periods (P>0.05). Preischemic basal coronary flow was significantly increased in all MLA350 but not MLA35 mice. Myocardial infarct size was reduced significantly, from 26.9+/-2.9% of risk area in vehicle-treated mice to 13.5+/-2.4% in the MLA350 group (mean+/-SEM, P<0.05). This reduction in infarct size was accompanied by augmented nitrite/nitrate accumulation, from 0.23+/-0. 05 nmol/mg protein in the vehicle group to 0.97+/-0.27 nmol/mg protein in MLA350 mice (P<0.01). Infarct size increased significantly, to 22.2+/-2.8% after treatment with SMT in the MLA350 group. Furthermore, MLA350 failed to reduce infarct size in iNOS knockout mice (25.5+/-3.6%). CONCLUSIONS: These results demonstrate a direct association of infarct size reduction with increased NO production with MLA350. An obligatory role for iNOS in mediating the cardioprotective effect induced by MLA was confirmed with the pharmacological inhibition and gene knockout mice.

Gene transfer of heat-shock protein 70 reduces infarct size in vivo after ischemia/reperfusion in the rabbit heart.

BACKGROUND: Heat-shock protein 70 (HSP 70) plays a role in myocardial protection. No studies are available, however, to show that direct gene transfer of HSP 70 reduces myocardial infarction in vivo. METHODS AND RESULTS: Rabbit hearts were injected with vehicle or Ad.HSP70 at 3 sites (1.5x10(9) pfu, 50 microL/site) in the left ventricle (LV). Four days later, hearts were removed, and expression of inducible (HSP 70) and constitutive (HSC 70) proteins was measured in the LV and right ventricle (RV). Subsets of 5 to 7 animals in the vehicle-, Ad.lacZ-, and Ad.HSP70-treated groups were subjected to 30 minutes of ischemia and 3 hours of reperfusion. Infarct size was measured by tetrazolium staining. Increased expression of HSP 70 was observed in LV injected with Ad.HSP70 compared with vehicle-treated hearts. HSP 70 was undetectable in RV, the noninjected region of the heart. The expression of HSC 70 remained unchanged in hearts treated with vehicle or Ad.HSP70. Infarct size (% risk area) decreased to 24.5+/-2.8 in Ad.HSP70-injected hearts compared with 41.9+/-2.8 and 42.7+/-2.5 in the vehicle- and Ad.LacZ-treated hearts (P<0.01). The infarct size was not different between the vehicle- and Ad.LacZ-treated hearts (P>0.05). The risk areas (% of LV) were not different among the 3 groups, ie, 50.1+/-5.2, 47.7+/-3.5, and 53.3+/-2.9 in vehicle-, Ad.lacZ-, and Ad.HSP70-treated groups (P>0.05). CONCLUSIONS: Direct gene delivery of HSP 70 in vivo reduces the severity of ischemic injury in the heart.

The oxygen free radical system: potential mediator of myocardial injury.

The sequential univalent reduction of oxygen gives rise to very reactive intermediate products including superoxide anion radical, hydrogen peroxide and free hydroxyl radicals. Normally, the tissue concentration of these intermediate products of oxygen is severely limited; however, if oxygen free radicals are produced in excess of the capacity of the tissues to eliminate them, they may cause serious damage. The biochemistry and possible sources of free radical generation in animal models of ischemic/reperfusion injury are reviewed. The ability of scavengers of oxygen free radicals to improve mechanical, mitochondrial and sarcoplasmic reticulum function in animal models of ischemic/reperfusion injury suggests that oxygen free radicals are partly responsible for myocardial injury in these models. Future research should be directed at establishing the relevance of oxygen radical-mediated myocardial injury in the experimental setting to analogous clinical situations.

YY-1 and c-Jun transcription factors participate in the repression of the human involucrin promoter.

The human involucrin gene, which encodes a precursor of the keratinocyte cornified layer, is strongly expressed in response to differentiation stimuli. Earlier studies suggested that YY1 and components of the AP-1 family might participate in the silencing of involucrin in proliferating keratinocytes. This study shows that overexpression of either YY1 or c-Jun represses transcription of the human involucrin gene in multiplying keratinocytes. Transient overexpression and site-directed mutagenesis experiments of the involucrin 5'-non-coding region (5'-NCR) confirmed that YY1 and c-Jun repress involucrin transcription. This repression involves the distal zinc fingers of YY1 protein and the DNA binding and leucine zipper domains of c-Jun. The results with protein pull-down experiments are consistent with the hypothesis that interaction of YY1 with c-Jun is an important mechanism for involucrin repression. Cotransfection of YY1 modified the stimulatory function of mutant c-Jun proteins independently of their DNA binding capacity suggesting that interactions may be more complex in vivo. Additionally, c-Jun protein levels are affected by differentiation stimuli indicating the importance of c-Jun in the YY1 repression pathway. Thus YY1 and c-Jun have an important role in epidermal differentiation by negatively regulating the human involucrin gene.

The oxygen free radical system: from equations through membrane-protein interactions to cardiovascular injury and protection.

Highly toxic oxygen radicals and their metabolites have been implicated in the pathogenesis of ischaemia/reperfusion injury. These reactive oxygen species include the superoxide anion, hydrogen peroxide, hydroxyl radical, and singlet oxygen. The central theme of this review is first to discuss the basic mechanisms of free radical generation from various potential sources, to point out and emphasise the growing importance of the role of singlet oxygen, and then to discuss in depth membrane-protein interactions that ultimately lead to myocardial damage and dysfunction. With this background, we highlight several novel therapeutic strategies aimed at interrupting the oxygen free radical mediated component of ischaemia/reperfusion injury. It is hoped that this thesis will then serve as a future impetus to challenge these hypotheses and further build on this truly unique system that has assumed such an important role in the pathophysiology of myocardial ischaemia/reperfusion and inflammation. "To those of us who are humbly exploring the mysteries of science, we must project our findings and model our systems. For if correct, we have made a small contribution and, if wrong, we have forced others to eventually think." A V Hill, on the occasion of the 50th anniversary of E H Starling's Linacre lecture (University College, London, 1968).

Free radical mediation of the effects of acidosis on calcium transport by cardiac sarcoplasmic reticulum in whole heart homogenates.

Generation of oxygen free radicals by xanthine acting on xanthine oxidase as a substrate significantly depressed calcium transport by sarcoplasmic reticulum in canine whole heart homogenates at 37 degrees C. At pH 7.0, this effect was completely inhibited by the addition of superoxide dismutase (SOD), a scavenger of the superoxide anion radical. At pH 6.4, SOD (5 to 20 micrograms X ml-1) was ineffective but catalase (20 micrograms X ml-1) was able to inhibit the effects of the xanthine-xanthine oxidase system. SOD + catalase (20 micrograms X ml-1) and SOD + mannitol, a scavenger of the hydroxyl free radical, inhibited the effects of the xanthine-xanthine oxidase system at pH 6.4. Preincubation at pH 6.4, in the absence of an exogenous free radical generating system, depressed calcium transport. This depression was more severe the longer the duration of incubation. However, return of the pH to 7.0 after preincubation at pH 6.4 partially restored calcium uptake velocity. The degree of reversibility was decreased the longer the period of incubation at pH 6.4. SOD reversed the effects of incubation at pH 6.4 for 5 min, but not those for incubations of 10 and 15 min. Mannitol alone was ineffective. The combinations of SOD and mannitol significantly reversed the effects of pH 6.4 up to 15 min. These results demonstrate that both exogenously generated and endogenously generated free oxygen radicals are capable of depressing calcium transport by cardiac sarcoplasmic reticulum in the whole heart homogenate in the presence of endogenous scavenging systems.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterisation of the excitation-contraction coupling system of the hypothermic myocardium following ischaemia and reperfusion.

The excitation-contraction coupling system of the globally ischaemic, hypothermic myocardium (60 min at 10 to 16 degrees C; I, n = 7) was studied by evaluating the functional integrity of the sarcoplasmic reticulum (SR) and the myofibrils (M). Comparison was made to the identical model followed by reperfusion (R, n = 7) and to sham-operated, time-matched controls (C, n = 7). Calcium uptake velocity from both the 60 min ischaemic group (I) and the reperfusion group (R) was significantly depressed (c = 0.960 +/- 0.05, I = 0.535 +/- 0.033, R = 0.662 +/- 0.035 micromolCa2+ . mg-1 . min-1, P less than 0.01). In contrast, SR . CA2+-ATPase activity was not affected by the hypothermic, ischaemic process (C = 1.150 +/- 0.08, I = 1.338 +/- 0.199 mumol Pi . mg-1 . min-1) but exhibited a small, significant depression after reperfusion (R = 0.940 +/- 0.04 mumol Pi . mg-1 . min-1, P less than 0.05). Myofibrillar pCa-ATPase curves in both experimental groups were significantly depressed (maximal ATPase activity: C = 0.18 +/- 0.01, I = 0.125 +/- 0.005, R = 0.115 +/- 0.01 mumol Pi . mg-1 . min-1; P less than 0.01). Kinetic analysis of the myofibrillar pCa-ATPase data, utilising double reciprocal plots, demonstrated an increase in injury in the hypothermic myocardium results from a breakdown of those subcellular structures responsible for the maintenance of the excitation-contraction coupling system. The ischaemic period, rather than reperfusion seems to be the major contributing factor in this sequence of pathological events.

Pretransplant transfusions in cardiac allograft recipients.

The role of pretransplant transfusion in cardiac allograft recipients was determined retrospectively in 68 patients. Three groups were studied: group 1 (n = 29) received no pretransplant transfusion, group 2 (n = 15) received transfusion over one year prior to transplantation, and Group 3 (n = 24) received 5 or 10 50-100 ml units of random donor red blood cells or buffy coat 2-4 weeks prior to transplantation. Data were analyzed for survival, number of rejection episodes, and number of infections. Immunosuppression included azathioprine, prednisone, and antithymocyte globulin. Survival in transfused patients (groups 2 and 3) was 68% and 51% at 1 and 5 years, respectively, while in the nontransfused population (group 1) it was 35% and 16%. The incidence of rejection episodes per year of survival was similar in the three groups (group 1: 1.3, group 2: 1.1, group 3: 1.3; P greater than 0.05). The number of infections per year of survival were greater in the transfused patients but this did not achieve statistical significance (group 1: 1.0, group 2: 1.2, group 3: 1.7; P greater than 0.05). Thus, we conclude that cardiac transplant recipients who have received blood transfusions prior to transplantation may have enhanced survival over patients who have not received preoperative transfusions.

Captopril and enalaprilat do not scavenge the superoxide anion.

The ability of captopril and enalaprilat, 2 angiotensin-converting enzyme (ACE) inhibitors, to scavenge superoxide anion radical was examined. With use of a number of superoxide-generating systems, such as xanthine-xanthine oxidase, phorbol myristate acetate-activated neutrophils, auto-oxidizing dihydroxyfumarate, and auto-oxidation of epinephrine to adrenochrome, captopril was seen not to scavenge superoxide directly, because it did not inhibit superoxide-dependent cytochrome c or nitro-blue tetrazolium reduction. Superoxide-dependent cytochrome c reduction was inhibited only when captopril was preincubated with a lower concentration of cytochrome c (22 microM). This effect was due to a decrease in the concentration of cytochrome c, because captopril reduced cytochrome c directly. When this effect was compensated for, no cytochrome c reduction induced by superoxide was observed. Captopril inhibited the auto-oxidation of epinephrine to adrenochrome at pH 10.2 where this auto-oxidation is superoxide-dependent, and at pH 7.8 where it is superoxide-independent and superoxide dismutase insensitive. It appears that captopril, in this respect, acted as a nonspecific antioxidant, probably by reducing an intermediate in the complex oxidation of epinephrine to adrenochrome. Therefore, caution may be used in interpreting the role of captopril in the attenuation of reperfusion-induced myocardial dysfunction and in attributing this effect to the inhibition of free radical mechanism.

Superoxide radical production after phorbol ester stimulation in neutrophils of aged donors.

Superoxide anion radical production was studied in purified neutrophils of young and old donors after stimulation with phorbol 12-myristate 13-acetate to determine whether phorbol-stimulated activation of NADPH-oxidase was altered by aging. Superoxide radical production of neutrophils of healthy ambulatory elderly (mean age 73 years) was increased compared to young adult controls. Expressed as nmol superoxide/min/mg protein, however, old cells were no different from young. Neutrophils of the elderly contained nearly 20% more protein/cell than young cells, yet neutrophil diameter and volume were not increased in the old cells. Binding affinity and maximum binding capacity of 3H-phorbol 12,13-dibutyrate were similar in young and old neutrophils. Maximum binding capacity was similar whether expressed on a per cell or per mg protein basis. Although others have suggested that initial plasma membrane events leading to superoxide radical production are diminished in aging cells, these studies show that intracellular phases of the mechanisms leading to superoxide radical production are maintained. Superoxide production rate per cell is increased in older persons, associated with a higher protein content per cell but not larger cell size.

Inhibition by free radical scavengers and by cyclooxygenase inhibitors of the effect of acidosis on calcium transport by masseter muscle sarcoplasmic reticulum.

In vitro, arachidonic acid depressed calcium transport by sarcoplasmic reticulum (SR) in the homogenate of canine masseter muscle. This effect was inhibited by superoxide dismutase (SOD), a scavenger of the superoxide anion radial ( . O-2), at pH 7.0, and by SOD plus d-mannitol, a scavenger of hydroxyl free radical ( . OH), at pH 5.5. Indomethacin and 2-aminomethyl-4-tert-butyl-6-propionyl phenol (ONO-3144), a compound known to accelerate the conversion of prostaglandin G2 (PGG2) to PGH2 and scavenge free radicals, inhibited the effect of arachidonic acid at both pH 7.0 and pH 5.5. PGG2, but not PGH2, duplicated the effect of arachidonic acid. The effect of PGG2 on SR function was similar to that of exogenous free radicals generated from the xanthine-xanthine oxidase system. Incubation at pH 5.5, in the absence of an exogenous free-radical generating system, depressed SR calcium transport in the homogenate and in isolated SR. This effect in the homogenate was inhibited by indomethacin or by ONO-3144. At 10-min incubation at pH 5.5, SOD partially and temporarily reversed the depressant effect of acidosis. The addition of SOD plus d-mannitol completely reversed the system. d-Mannitol alone was ineffective. Arachidonic acid was able to mimic these effects of acidosis, except that arachidonic acid further depressed isolated SR calcium transport. These results demonstrate that acidosis can depress SR calcium transport in the homogenate of masseter muscle by an oxygen-free radical mechanism by the generation of . O-2 and . OH. Our results also demonstrate that significant oxygen radical generation can occur through the cyclooxygenase pathway of arachidonic acid metabolism at an acidotic pH in the cellular environment outside of the SR of the muscle cell, and seems to be responsible for the generation of the . OH derived from . O-2.

The heart as a target organ of immune injury.

Over the last 10 years, our knowledge of immunologically mediated processes involving the myocardium appears to have made quantum leaps. New and important disease entities such as AIDS have appeared and the cardiologist now becomes an important member of the "AIDS team." Our understanding of "older diseases" such as sarcoidosis, Lyme disease, systemic lupus and other connective tissue syndromes has significantly increased. The concept of high-dose steroid therapy for these processes may, in fact, turn out to be futile and more selective, as less dangerous immunosuppression is being introduced. This concept has significantly advanced in the field of cardiac transplantation where immunosuppression has now been usurped by specific immunotherapy aimed at selective aspects of the immune sequence. New and exciting concepts will emerge from the molecular biology laboratory that will have direct bearing on the management of patients with cardiovascular disorders. This information explosion will force the cardiovascular physician to become more in tune with the world of immunology and molecular biology. Many obvious, significant problems remain, such as accelerated atherosclerosis in the transplant patient and the role of myocarditis in the patient with heart failure. However, it will truly be an exciting decade in which to work and watch the unraveling of these mysteries and hopefully, the study of today's problems will give way to solutions and a clearer understanding of the heart as a target of immune injury.

Enhancement of crystalloid cardioplegic protection against global normothermic ischemia by superoxide dismutase plus catalase but not diltiazem in the isolated, working rat heart.

Oxygen-derived free radicals and intracellular calcium overload have been implicated as mediators of myocardial ischemia/reperfusion injury. We hypothesized that free radical scavengers or calcium channel blockers could enhance the protection afforded the isolated, working rat heart by crystalloid cardioplegia against this type of injury at 37 degrees C. Hearts from 42 male rats in seven groups (n = 6) were studied in an isolated, working heart preparation measuring aortic flow (ml/min/gm dry wt), peak systolic pressure (mm Hg), coronary artery flow (ml/min/gm dry wt), and calculated coronary vascular resistance (dyne.sec.cm-5/gm dry wt). Creatine kinase and lactate dehydrogenase release were measured before ischemia and at various times during the postischemic reperfusion period. Time-matched control hearts (group 1) were perfused for 2 hours. After finding that 30 minutes of ischemia and 10 minutes of reperfusion (group 2) produced significant (p less than 0.01) functional impairment that was completely protected (group 3) by a preischemic bolus of St. Thomas' Hospital cardioplegic solution, we again found significant (p less than 0.01) functional impairment after 40 minutes of ischemia and 10 minutes (group 4) or 20 minutes (group 5) of reperfusion despite a preischemic bolus of St. Thomas' Hospital cardioplegic solution. Diltiazem (10 mg/L) plus St. Thomas' Hospital cardioplegic solution (group 6) did not significantly (p less than 0.01) enhance functional recovery. Addition of superoxide dismutase plus catalase (200 microns/ml) (group 7) produced marked improvement in functional recovery that did not differ significantly (p less than 0.01) from control results (group 1). The creatine kinase and lactate dehydrogenase data strongly supported the preceding functional data. Coronary flow and vascular resistance were not significantly (p less than 0.01) changed from control values in any group. We conclude that the addition of superoxide dismutase and catalase but not diltiazem to St. Thomas' Hospital cardioplegic solution can significantly enhance myocardial protection against normothermic ischemia/reperfusion injury. This implicates oxygen-derived free radicals as mediators of this type of injury.

Ischemia and activated neutrophils alter coronary microvascular but not epicardial coronary artery reactivity.

Activated neutrophils have been implicated in reperfusion injury and the no-reflow phenomenon of intramyocardial arterioles. This study tested the hypothesis that ischemia and activated neutrophils impair coronary endothelial and smooth muscle cell function of epicardial and intramyocardial coronary arteries. Alteration of smooth muscle and endothelial cell function in epicardial coronary arteries (3 mm diameter) and intramyocardial coronary arteries (0.3 mm diameter) was compared by means of a myograph after exposure to ischemia (epicardial, 160 minutes, intramyocardial, 30 minutes), activated neutrophils, and combined ischemia and activated neutrophils. Morphologic studies at the ultrastructural level were done by means of scanning electron microscopy. Epicardial coronary artery function was normal after ischemia, storage with activated neutrophils, and ischemia followed by storage with activated neutrophils. Intramyocardial artery function, however, was altered. Contraction to a 45 mmol/L concentration of potassium chloride after ischemia and storage with activated neutrophils was increased (p = 0.06). Smooth muscle relaxation was significantly decreased after ischemia, but storage with activated neutrophils did not further decrease smooth muscle relaxation. Endothelium-dependent relaxation to bradykinin was significantly decreased after combined ischemia and incubation with activated neutrophils (p < 0.05). Sensitivity to bradykinin was decreased after both ischemia alone (p < 0.05) and activated neutrophils alone (p < 0.05). Similar morphologic alterations were found in epicardial and intramyocardial arteries after ischemia. Activated neutrophils alone minimally damaged endothelial cells of nonischemic intramyocardial and epicardial arteries. Endothelial cells of both arteries exposed to ischemia alone showed evidence of ischemic damage, including endothelial cell blebbing, nuclear bulging, and appearance of large holes in the cell surface. Severe endothelial cell damage was found after combined ischemia and storage with neutrophils: total destruction of cells and exposure of the basal lamina. Endothelial damage, therefore, correlated with artery function in intramyocardial but not in epicardial arteries. These results indicate that ischemia is a prerequisite for severe neutrophil injury of intramyocardial artery endothelium-mediated relaxation. This may explain no-reflow phenomenon in arterioles concurrent with myocardial reperfusion injury.

Prevention of free radical-induced myocardial reperfusion injury with allopurinol.

Growing evidence supports the concept that oxygen free radicals are an important cause of myocardial ischemic and reperfusion injury. This study was designed to determine if toxic oxygen metabolites may exacerbate ischemic injury upon reoxygenation. Left ventricular function was studied in a group of seven dogs receiving intermittent, 4 degrees C, hyperosmolar, hyperkalemic (KCI 25 mEq/L) saline cardioplegic solution. This group was compared to a group (n = 7) receiving a hyperkalemic (KCI 25 mEq/L) cardioplegic solution designed to scavenge superoxide anion and hydroxyl radical: superoxide dismutase (3,000 U/ml) and mannitol (325 mOsm/L). A third group of five animals received allopurinol pretreatment (50 mg/kg/day) for 72 hours and hyperkalemic saline cardioplegic solution. After 60 minutes of ischemia (10 degrees to 15 degrees C) and 45 minutes of reperfusion, left ventricular mechanical function was better in the groups receiving free radical scavengers and allopurinol pretreatment than in the group receiving only hyperkalemic saline cardioplegic solution. Free radical scavengers preserved myocardial function in this model of hypothermic global ischemia and reperfusion. Our data support the concept that injury occurs primarily during reperfusion with the generation of oxygen free radicals via the hypoxanthine-xanthine oxidase reaction. Allopurinol has potential clinical application in the prevention of reperfusion injury.

Inhibition of surgically induced ischemia/reperfusion injury by oxygen free radical scavengers.

Recent experimental work implicates oxygen free radicals as mediators of ischemia/reperfusion injury. A simple cardioplegic solution was designed to scavenge superoxide anion and hydroxyl free radical with superoxide dismutase (10 micrograms/ml), mannitol (325 mOsm/L), and KCl 25 mEq/L (FRS). Hemodynamic and subcellular functions were studied in seven in situ canine models of hypothermic global ischemia receiving FRS, compared to a group (n = 7) receiving hyperosmolar, hyperkalemic saline (HSK) and to a standard model of topical hypothermia (TH, n = 5). Following 60 minutes of ischemia (10 degrees to 15 degrees C), hearts were reperfused and rewarmed. After 45 minutes of reperfusion, left ventricular peak systolic pressure (LVPSP), developed pressure (LVDP), dP/dt max, -dP/dt max, compliance, and elastic stiffness constant (K) were improved in the FRS group and not significantly different from control. Sarcoplasmic reticulum (SR) calcium transport in the FRS group was significantly improved (control = 1.077 +/- 0.022, TH = 0.754 +/- 0.018, HSK = 0.725 +/- 0.05, and FRS = 0.966 +/- 0.05 mumol/mg-min). Calcium adenosine triphosphatase (ATPase) activity did not differ significantly from control at pH 7.0. In this model of hypothermic global ischemia and reperfusion, free radical scavengers provide significant protection of mechanical and subcellular function. These findings support the hypothesis that oxygen free radicals are important mediators of myocardial ischemia and reperfusion injury.

Hypercholesterolemia in long-term survivors of heart transplantation: an early marker of accelerated coronary artery disease.

Coronary artery disease remains a significant long-term problem for survival after heart transplantation. Hyperlipidemia is a known risk factor for coronary artery disease in the general population, but the role of hyperlipidemia in cardiac allograft recipients has not been elucidated. To study this problem, we retrospectively reviewed 38 heart transplant recipients who survived more than 3 years after surgery and looked at age, development of diabetes, drug protocol, and development of hypercholesterolemia for a possible correlative or predictive value to the development of early coronary artery disease after heart transplantation. Eleven patients were identified as having coronary disease by the third year after transplantation. High-risk cholesterol values (in milligrams per deciliter) at 6 months after heart transplantation were defined as follows: for ages 10 to 20, 190; 20 to 30, 220; 30 to 40, 240; 40+, 260. We found a strong predictive value with high-risk lipid profiles (p less than 0.01) for the development of coronary artery disease by the third year. No significance was found for a low-risk value, the development of diabetes, or hypertension. All patients below the age of 20 years had coronary artery disease by the third year after transplantation. We conclude that a high-risk cholesterol value at 6 months after transplantation is a strong predictor for development of accelerated coronary artery disease and early graft failure. This has major implications for management of hyperlipidemia in the cardiac allograft recipient.