[Anesthesiological aspects of liver transplantation]. / Anästhesiologische Aspekte bei der Lebertransplantation.

Liver transplantation (LTPL) is the only curative option for patients with end stage liver disease (ESLD) or with hepatocellular carcinoma (HCC). Eurotransplant in Leiden, the Netherlands, is responsible for organ allocation. The model of end stage liver disease (MELD) score, which describes the severity of the liver disease, is decisive for organ allocation. The heterogeneous patient collective and hepatic-related comorbidities and their dynamics represent challenges. The anesthesiologist is responsible for evaluating the overall prognosis, whereby cardiac, pulmonary, renal and neurological comorbidities must be taken into consideration. During LTPL surgery is divided into several stages. Besides volume management, heat preservation and coagulation management, major challenges for the anesthesiologist are hemodynamic stabilization and regulation of the acid-base balance.

A comparison of single particle tracking and temporal image correlation spectroscopy for quantitative analysis of endosome motility.

Single particle tracking (SPT) is becoming a standard method to extract transport parameters from time-lapse image sequences of fluorescent vesicles in living cells. Another method to obtain these data is temporal image correlation spectroscopy (TICS), but this method is less often used for measurement of intracellular vesicle transport. Here, we present an extensive comparison of SPT and TICS. First we examine the effect of photobleaching, shading and noise on SPT and TICS analysis using simulated image sequences. To this end, we developed a simple photophysical model, which relates spatially varying illumination intensity to the bleaching propensity and fluorescence intensity of the moving particles. We found that neither SPT nor TICS are affected by photobleaching per se, but the transport parameters obtained by both methods are sensitive to the signal-to-noise ratio. In addition, the number of obtained trajectories in SPT is affected by noise. Diffusion constants determined by TICS are significantly overestimated when large immobile fluorescent structures are present in the image sequences, while the opposite is true for SPT. To improve the performance of both techniques, we compare three different methods for image denoising. Appropriate denoising significantly reduced the effect of noise and of immobile structures on both methods. Shape fluctuations of simulated particles had a more pronounced effect on TICS than on SPT analysis. In denoised images of fluorescent beads or cytosolic vesicles containing fluorescent protein NPC2 in human skin fibroblast cells, the transport parameters acquired by SPT and TICS were comparable emphasizing the value of both analysis methods.

Cyclic ADP-ribose production by CD38 regulates intracellular calcium release, extracellular calcium influx and chemotaxis in neutrophils and is required for bacterial clearance in vivo.

Cyclic ADP-ribose is believed to be an important calcium-mobilizing second messenger in invertebrate, mammalian and plant cells. CD38, the best-characterized mammalian ADP-ribosyl cyclase, is postulated to be an important source of cyclic ADP-ribose in vivo. Using CD38-deficient mice, we demonstrate that the loss of CD38 renders mice susceptible to bacterial infections due to an inability of CD38-deficient neutrophils to directionally migrate to the site of infection. Furthermore, we show that cyclic ADP-ribose can directly induce intracellular Ca++ release in neutrophils and is required for sustained extracellular Ca++ influx in neutrophils that have been stimulated by the bacterial chemoattractant, formyl-methionyl-leucyl-phenylalanine (fMLP). Finally, we demonstrate that neutrophil chemotaxis to fMLP is dependent on Ca++ mobilization mediated by cyclic ADP-ribose. Thus, CD38 controls neutrophil chemotaxis to bacterial chemoattractants through its production of cyclic ADP-ribose, and acts as a critical regulator of inflammation and innate immune responses.

Regulated expression of mouse mammary tumor proviral genes in cells of the B lineage.

We evaluated the expression of mouse mammary tumor proviral (MMTV) transcripts during B cell ontogeny and compared levels of RNA in B lymphocytes and B cell lines with levels in other cells of the hematopoietic lineage and in a mammary cell line. We demonstrate that MMTV transcripts are expressed as early as the pro-B cell stage in ontogeny and are expressed at basal constitutive levels throughout most of the B cell developmental pathway. The level of MMTV expression in B cells is similar to constitutive levels in mammary tissues and two to three orders of magnitude greater than in activated T cells. Levels of MMTV transcripts in B cells are not solely due to positional effects. Transient transfection assays showed that MMTV upregulation resulted from transcriptional activation of the viral LTR, indicating that there are specific and inducible transcription factors that regulate MMTV expression in B cells. MMTV transcripts could not be upregulated in pre-B cell lines but could be induced in some mature B cell lines. There was a correlation between the ability to stimulate B cells to secrete antibody and the ability to induce upregulated MMTV expression. Evidence is presented that suggests that the principal transcription factors involved in MMTV expression do not include the B cell factors OTF-2 or NF-kappa B, but rather are likely to be novel factors that are induced during differentiation to antibody secretion. A hypothesis for why mammary tumor viruses are well adapted for expression in cells of the B lineage is proposed, and the implications of this for the documented influence of MMTV gene products on the T cell repertoire are discussed.

Major histocompatibility complex-restricted recognition of retroviral superantigens by V beta 17+ T cells.

It has been established that at least some V beta 17+ T cells interact with an endogenous superantigen encoded by the murine retrovirus, Mtv-9. To analyze the role of major histocompatibility complex (MHC) class II molecules in presenting the Mtv-9 encoded superantigen, vSAG-9 to V beta 17+ hybridomas, a panel of nine hybridomas was tested for their ability to respond to A20/2J (H-2d) and LBK (H-2a) cells which had been transfected with the vSAG-9 gene. Whereas some of the hybridomas recognized vSAG-9 exclusively in the context of H-2a, other hybridomas recognized vSAG-9 exclusively in the context of H-2d or in the context of both H-2d and H-2a. These results suggest that: (a) the class II MHC molecule plays a direct role in the recognition of retroviral superantigen by T cells, rather than serving simply as a platform for presentation; and, (b) it is likely that components of the TCR other than V beta are involved in the vSAG-9/TCR/class II interaction.

Endogenous superantigen expression is controlled by mouse mammary tumor proviral loci.

Superantigens are defined by their ability to stimulate T cells based predominantly on their V beta expression and ability to delete T cells in the thymus when expressed endogenously. We show here that the expression of one endogenous superantigen, Etc-1, is controlled by the expression of the open reading frame region of the 3' long terminal repeat of the mouse mammary tumor proviral gene, Mtv-9. We show that Mtv-8 controls a superantigen with similar specificity, and that both Mtv-8 and Mtv-9 stimulate some V beta 17+ T cells. A third provirus, Mtv-6, controls a superantigen with specificity for V beta 3. Data presented raise the possibility that endogenous superantigens may compete for class II molecules in a single B cell.

Formation and hydrolysis of cyclic ADP-ribose catalyzed by lymphocyte antigen CD38.

CD38 is a 42-kilodalton glycoprotein expressed extensively on B and T lymphocytes. CD38 exhibits a structural homology to Aplysia adenosine diphosphate (ADP)-ribosyl cyclase. This enzyme catalyzes the synthesis of cyclic ADP-ribose (cADPR), a metabolite of nicotinamide adenine dinucleotide (NAD+) with calcium-mobilizing activity. A complementary DNA encoding the extracellular domain of murine CD38 was constructed and expressed, and the resultant recombinant soluble CD38 was purified to homogeneity. Soluble CD38 catalyzed the formation and hydrolysis of cADPR when added to NAD+. Purified cADPR augmented the proliferative response of activated murine B cells, potentially implicating the enzymatic activity of CD38 in lymphocyte function.

Interleukin-5 (IL-5) and IL-6 define two molecularly distinct pathways of B-cell differentiation.

Interleukin-5 (IL-5) and IL-6 have both been reported to act as B-cell differentiation factors by stimulating activated B cells to secrete antibody. However, it has not been possible to directly compare the effects of these two lymphokines because of the lack of a suitable B-cell line capable of responding to both. We have identified a clonal, inducible B-cell lymphoma, CH12, that has this property. Both IL-5 and IL-6 can independently stimulate increases in steady-state levels of immunoglobulin and J-chain mRNA and proteins, and they both induce the differentiation of CH12 into high-rate antibody-secreting cells. Nevertheless, there are significant differences in the activities of these two lymphokines. First, while IL-6 acts only as a differentiation factor, IL-5 also augments the proliferation of CH12 cells. Second, the differentiation stimulated by IL-5 but not by IL-6 is partially inhibited by IL-4. Inhibition of IL-5-induced differentiation was not at the level of IL-5 receptor expression, since IL-4 did not inhibit IL-5-induced proliferation. Third, IL-5 but not IL-6 stimulated increased mouse mammary tumor proviral gene expression in CH12 cells. These results demonstrate that while both IL-5 and IL-6 may act as differentiation factors for B cells, they induce differentiation by using at least partially distinct molecular pathways. Our results also establish that B cells characteristic of a single stage of development can independently respond to IL-4, IL-5, and IL-6.

Cellular effects and metabolic stability of N1-cyclic inosine diphosphoribose and its derivatives.

BACKGROUND AND PURPOSE: Recently, a number of mimics of the second messenger cyclic ADP-ribose (cADPR) with replacement of adenosine by inosine were introduced. In addition, various alterations in the molecule ranging from substitutions at C8 of the base up to full replacement of the ribose moieties still retained biological activity. However, nothing is known about the metabolic stability and cellular effects of these novel analogues. EXPERIMENTAL APPROACH: cADPR and the inosine-based analogues were incubated with CD38, ADP-ribosyl cyclase and NAD-glycohydrolase and metabolism was analysed by RP-HPLC. Furthermore, the effect of the analogues on cytokine expression and proliferation was investigated in primary T-lymphocytes and T-lymphoma cells. KEY RESULTS: Incubation of cADPR with CD38 resulted in degradation to adenosine diphosphoribose. ADP-ribosyl cyclase weakly catabolised cADPR whereas NAD-glycohydrolase showed no such activity. In contrast, N1-cyclic inosine 5'-diphosphoribose (N1-cIDPR) was not hydrolyzed by CD38. Three additional N1-cIDPR analogues showed a similar stability. Proliferation of Jurkat T-lymphoma cells was inhibited by N1-cIDPR, N1-[(phosphoryl-O-ethoxy)-methyl]-N9-[(phosphoryl-O-ethoxy)-methyl]-hypoxanthine-cyclic pyrophosphate (N1-cIDP-DE) and N1-ethoxymethyl-cIDPR (N1-cIDPRE). In contrast, in primary T cells neither proliferation nor cytokine expression was affected by these compounds. CONCLUSIONS AND IMPLICATIONS: The metabolic stability of N1-cIDPR and its analogues provides an advantage for the development of novel pharmaceutical compounds interfering with cADPR mediated Ca2+ signalling pathways. The differential effects of N1-cIDPR and N1-cIDPRE on proliferation and cytokine expression in primary T cells versus T-lymphoma cells may constitute a starting point for novel anti-tumor drugs.

Degradation of mecillinam in aqueous solution.

The hydrolysis of mecillinam in aqueous solution (37 degrees) was studied at pH 2-10. The degradation products observed by TLC and NMR were identified and quantified. Several of these compounds were synthesized. Mecillinam and the key degradation product, (6R)-6-formamidopenicillanic acid, underwent reversible 6-epimerization in basic solution. Some of the thiazolidine derivatives formed epimerized at position 2. In contrast to penicillins, the degradation pattern of mecillinam becomes more complex with increasing pH. Rate constants for some processes are given.

Peripheral artery disease in patients with coronary artery disease.

The prevalence of peripheral vascular disease in patients with coronary artery disease has been investigated in many different ways and depends on the diagnostic methods and the definition of the atherosclerotic manifestations in the different vascular beds. In this study we used the non-invasive methods digital volume pulse plethysmography and ankle and toe blood pressure measurements to identify arterial abnormalities in the lower limbs in 58 patients (49 males and 9 females; age 37-72 years) examined with coronary angiography. The prevalence of peripheral artery disease was 22%, in agreement with the results of most previous investigations. There was a tendency towards increasing prevalence of peripheral artery disease with more advanced coronary artery disease: 14% of the patients with no or minimal coronary atheromotous lesions, 18% of the patients with moderate coronary atheromotous lesions and 32% of the patients with marked coronary atheromotous disease. For this reason a non-invasive investigation of the peripheral arterial circulation should be included early in the clinical consideration of patients with chest pain or similar symptoms suggesting coronary heart disease. Toe pressure measurement appears to be the most appropriate technique being rather simple in management and also in evaluation of results.

Thrombolytic treatment with i.v. brinase of advanced arterial obliterative disease of the limbs.

The material includes 17 patients suffering from different degrees of chronic peripheral arterial disease (11 chronic patients stage III and IV, two patients with acute arterial occlusion, and four patients stage II). Presence and extent of arterial occlusion was ascertained by initial arteriography. In twelve of the patients amputation had been considered. The patients were treated by a series of i.v. infusions of brinase, a proteolytic enzyme from Aspergillus oryzae. The brinase inhibitor capacity in plasma was determined by the azocollagen technique. Dosage of brinase was calculated to retain a rest-inhibitor capacity in order to avoid free proteolytic activity. In five patients the enzyme was also given preoperatively by intra-arterial instillation prior to a series of i.v. brinase infusions. Thirteen patients showed clinical improvement after brinase treatment. The condition of two patients remained unchanged, and in two patients amputation could not be avoided. In fourteen patients the treatment results were followed by measurement of peripheral systolic blood pressure. In ten patients obvious increase of the peripheral systolic blood pressure was observed. Cutaneous microcirculation was studied in seven patients by i.v. sequential fluorescein angiography and signs of improved microcirculation (appearance time, intensity and/or extent of fluorescence) were found in all examined patients. One patient with acute arterial occlusion of the right leg with obstruction of blood flow from the external iliac artery showed complete disobliteration after a series of i.v. brinase infusions. Bleeding complications associated with brinase treatment were not observed in the material. In three patients brinase treatment was discontinued because of complications (2 brinase, 1 heparin).

Dosage of i.v. brinase in man based on brinase inhibitor capacity and coagulation studies.

In 17 patients a total of 148 brinase infusions were given. All patients but two had anticoagulant treatment (dicoumarol or heparin) during the brinase series. Dosage of brinase was based on determination of brinase inhibitor capacity in plasma (azocollagen technique) prior to infusion of the enzyme. Iv infusion of brinase lowered inhibitors in plasma. Good correlation was found between expected lowering and measured inhibitor values after brinase infusion. The stipulated safety margin for brinase inhibitor capacity could be maintained. alpha 1-antitrypsin showed irregular changes and alpha 2-macroglobulin values were decreased by iv infusions of brinase. Fibrinogen values were somewhat lowered after iv brinase infusion. Values for fibrinogen degradation products increased and the ethanol gelation test became positive. Thrombotest values were lowered and the activated partial thromboplastin time was prolonged in patients receiving dicoumarol and iv heparin respectively. Changes in other coagulation parameters were insignificant. In two patients transient renal failure was recorded, laboratory data indicated intravascular coagulation as a possible cause. None of these two patients were on anticoagulant treatment. One patient developed a haematoma of the forefoot during massive iv heparin treatment during a series of iv infusions of brinase. Bleeding complications due to brinase treatment were not observed.

Intravenous hydroxyethylrutosides combined with long-term oral anticoagulation in atherosclerotic nonreconstructable critical leg ischemia: a retrospective study.

OBJECTIVE: To evaluate in a group of seriously diseased patients with nonreconstructable chronic critical leg ischemia (CLI), treated by a combination of i.v. hydroxyethylrutosides (HR)* and oral anticoagulation (AC) by warfarin, the short-term effects on the cutaneous microvascular blood perfusion of the soles of feet and especially the long-term clinical outcome in terms of amputation and death. DESIGN: A retrospective comparison between two groups of patients, HR + AC and a comparable reference group, fulfilling the same inclusion and exclusion criteria corresponding to the definition of CLI according to the Second European Consensus Document (1991). Clinical follow-up in both groups was made after 1, 3, 6, 12, and 24 months. SETTING: Patients were examined at university departments of clinical physiology with special interest in peripheral vascular disease, in cooperation with colleagues at university departments of surgery, internal medicine and dermatology of Karolinska Hospital, Södersjukhuset and Huddinge Hospital. PATIENTS: A total of seventy patients with CLI according to the definition of the Second European Consensus Document, 1991, ie, besides severe rest pain or ischemic lesions also a toe blood pressure < 30 mg Hg. Group with HR + anticoagulation (AC): 42 patients (19 diabetics, 23 nondiabetics). Reference group: 28 patients (18 diabetics, 10 nondiabetics). For distribution of age and toe blood pressure at baseline, see Table I. INTERVENTIONS: Therapy group: besides ordinary standard therapy, daily HR infusions for a mean period of 3.6 weeks + oral anticoagulation continued to the end of the study at 24 months. A comparable reference group on the same basic therapy but without the combination HR + AC. PARAMETERS IN EVALUATION: Short-term parameters: clinical data, skin temperature, and fluorescein imaging. Long-term outcome: amputation or death. RESULTS: Short-term and long-term results with HR + AC indicated that patients with severe CLI and very poor prognosis benefited in terms of survival and limb salvage from initial therapy with HR infusion combined with long-term oral anticoagulation. Results of this combined treatment seem at least comparable with those with i.v. prostacyclin analogies.

Minimally invasive and non-invasive diagnosis of carotid artery obstructive disease: an evaluation of supraorbital fluorescein angiography and ultrasonic duplex technique.

The carotid arteries of twenty-five patients with transient ischaemic attacks, minor stroke or amaurosis fugax were examined by conventional angiography, the ultrasonic duplex technique and supraorbital fluorescein angiography (SOFA). The results of the last two techniques (non-invasive and minimally invasive, respectively) were compared with the results of angiography. We found that the ultrasonic duplex technique is highly sensitive and specific for both high and low-grade carotid stenoses while the less costly SOFA can only identify stenoses equal to or more than 75%. However, since tight stenosis has proved to be an indication for surgical reconstruction, SOFA - or possibly the still simpler procedure with direct ocular inspection of the supraorbital fluorescence pattern without any recording - would be useful for initial screening in smaller units without access to ultrasonic duplex examination. In this way potential candidates for surgery can be identified without delay and forwarded to larger units for further supplementary examinations.

Secondary treatment of advanced cancer of the prostate with Zoladex.

Twelve patients with advanced prostatic carcinoma and relapse following previous hormone manipulation therapy were treated with Zoladex-depot every 4 weeks. The treatment was well tolerated and the endocrine response was satisfactory. However, no clinically important improvement was obtained.

Late recurrence of upper urinary tract urothelial tumours.

Two case reports of late recurrence of upper urinary tract urothelial tumours 13 years after ipsilateral local resection and 19 years after contralateral nephroureterectomy are used in the discussion on when to perform local resection. In accordance with existing literature we propose local resection in case of low-grade upper urinary tract urothelial tumours.

[Laser treatment of penile cancer]. / Laserbehandling af cancer penis.

The treatment of localized penile cancer has hitherto been surgical amputation of the penis. In our 12 cases, tumorectomy was performed by CO2 or ND:YAG-laser radiation with minimal tissue ablation. Local recurrences occurred and the patients must be followed regularly in the outpatient clinic. The recurrences were treated by repeated laser radiation. No patients died of penile cancer during a mean observation of 16 months (range 3-50). Laser tumorectomy has definitive therapeutic advantages compared with penile amputation, because the result is acceptable for the patient and his micturition and sexual life are not altered.

[Retinal damage and oral contraceptives]. / Retinaskader og orale kontraceptiva

PIP: 2 case histories of retinal damage in users of oral contraceptives (OCs) are discussed. The 1st, a 27-year-old woman who had used Eugynon for a year, had no history of cardiovascular disease of hemicrnaia. Ophthalmic examination showed vision in the right eye as less than 6/120, in the left 6/6, with indications of central serous chorio-retinpathy, with edematous center surrounded by small hemorrhages. After discontinuation of OCs, vision returned to 6/6 and paracentral scatoma disappeared. In the 2nd case a 37-year-old woman who had taken Eugynon and Ovulen for 1 year and Neolyndiol for 2 years complained of the appearance of a wedge-shaped shadow in her right eye. The patient had a history of metrorrhagia and hemicrania on the right side. Vision in both eyes was 6/6, but a paracentral scotoma in the right eye was present, a probable symptom of the patient's hypertensive spastic angiopathy. OCs were discontinued and propanol was administered, then discontinued due to symptoms of a scotoma in the left eye. The angiopathy disappeared but the ocular lesions remained. Ocular complications occur in about .07% of OC users. The damage results from arterial hypertension and changes in the macula lutea. Careful observation of blood pressure and ocular disturbances is the best preventative for ocular damage in OC users.^ieng

[Continuous monitoring of wound infections and other postoperative complications using MIKRO-ORT]. / Kontinuerlig overvågning af sårinfektioner og andre postoperative komplikationer med anvendelse af MIKRO-ORT.

Registration of 883 operations, performed on the Orthopedic Department, Roskilde County Hospital, from 06.20.1988 to 12.31.1988, is presented. 95.9% of all operations were registrated primarily. 2.6% superficial wound infections and 1.2% deep were registered. Other infections constituted 2.3%, other complications 4.5%. A significant increase in the incidence of deep wound infections in contaminated wounds was observed. We also found an increase in incidence in prolonged operations (NS). Where types of infections and complications were concerned pronounced extension of the hospitalization occurred. The 4.1% of operations not registered primarily, were more often performed in the evening and night time, were more often contaminated operations and were more often patients with more than one operation during the registration period. No significant loss of information could be found. It is concluded, that establishing a continuous surveillance of wound infections has benefited to the department's control of its infection rate. We were satisfied with the program MIKRO-ORT, which we have used for the registration.