Early and long-term results after reconstructive surgery in 42 children and two young adults with renovascular hypertension due to fibromuscular dysplasia and middle aortic syndrome.

OBJECTIVES: This retrospective study presents the early and late results of pediatric patients who underwent reconstructive surgery for renovascular hypertension (RVH) between 1979 and 2009. METHODS: From 1979 to 2009 44 patients (male 22; mean age 13±5.2 years, range 1-19 years; early childhood 7 [1-6 years], middle childhood 5 [7-10 years]; adolescents 32 [11-19 years]) with renovascular hypertension underwent surgery for abdominal aortic stenoses (n=6), renal artery stenosis (RAS) (n=25) or for combined lesions (n=13). Nineteen aortic stenoses (bypass/interposition 10/5, patch dilatation/thromboendarterectomy 2/2), 51 renal arteries (interposition 36, resection+reimplantation 13, patch dilatation/aneurysmorraphy 1 each), and 10 visceral arteries (resection+reimplantation 6, interposition 3, patch dilatation 1) were reconstructed. Each patient underwent duplex studies and if required intra-arterial digital subtraction angiography. Reoperations within 30 postoperative days were required in four (9%) of the patients for occlusion of four arteries (6%), achieving a combined technical success rate of 94%. RESULTS: After 114±81 months 36 patients were re-examined by duplex and magnetic resonance angiography (2 not surgery-related deaths 7/12 years postoperatively, 8 patients lived abroad). Twelve patients had required a second and three a third procedure. Hypertension was cured early/late postoperatively in 27%/56%, improved in 41%/44%, and remained unchanged in 32%/0%. Best late results were obtained in patients with isolated aortic disease and at the age of middle childhood. CONCLUSIONS: Reconstructive surgery for pediatric RVH yields good results at every age and every type of lesion. However, these children should be followed up closely and to avoid early cardiovascular disease and death in later life, surgery should not be delayed.

Association of exercise-induced hyperinsulinaemic hypoglycaemia with MCT1-expressing insulinoma.

AIMS/HYPOTHESIS: Exercise-induced hyperinsulinism (EIHI) is a hypoglycaemic disorder characterised by inappropriate insulin secretion following anaerobic exercise or pyruvate load. Activating promoter mutations in the MCT1 gene (also known as SCLA16A1), coding for monocarboxylate transporter 1 (MCT1), were shown to associate with EIHI. Recently, transgenic Mct1 expression in pancreatic beta cells was shown to introduce EIHI symptoms in mice. To date, MCT1 has not been demonstrated in insulin-producing cells from an EIHI patient. METHODS: In vivo insulin secretion was studied during an exercise test before and after the resection of an insulinoma. The presence of MCT1 was analysed using immunohistochemistry followed by laser scanning microscopy, western blot analysis and real-time RT-PCR of MCT1. The presence of MCT1 protein was analysed in four additional insulinoma patients. RESULTS: Clinical testing revealed massive insulin secretion induced by anaerobic exercise preoperatively, but not postoperatively. MCT1 protein was not detected in the patient's normal islets. In contrast, immunoreactivity was clearly observed in the insulinoma tissue. Western blot analysis and real-time RT-PCR showed a four- to fivefold increase in MCT1 in the insulinoma tissue of the EIHI patient compared with human pancreatic islets. MCT1 protein was detected in three of four additional insulinomas. CONCLUSIONS/INTERPRETATION: We show for the first time that an MCT1-expressing insulinoma was associated with EIHI and that MCT1 might be present in most insulinomas. Our data suggest that MCT1 expression in human insulin-producing cells can lead to EIHI and warrant further studies on the role of MCT1 in human insulinoma patients.

Structural white matter changes in adolescents and young adults with maple syrup urine disease.

OBJECTIVE: To get insight into the nature of magnetic resonance (MR) white matter abnormalities of patients with classic maple syrup urine disease (MSUD) under diet control. METHODS: Ten patients with classic MSUD and one with a severe MSUD variant (mean age 21.5 ± 5.1 years) on diet and 11 age and sex-matched healthy subjects were enrolled. Apart from standard MR sequences, diffusion weighted images (DWI), diffusion tensor images (DTI), and magnetization transfer images (MT) were obtained and comparatively analyzed for apparent diffusion coefficient (ADC), tensor fractional anisotropy (FA) and MT maps in 11 regions of interest (ROI) within the white matter. RESULTS: In MSUD patients DWI, DTI and FA showed distinct signal changes in the cerebral hemispheres, the dorsal limb of internal capsule, the brain stem and the central cerebellum. Signal intensity was increased in DWI with a reduced ADC and decreased values for FA. MT did not reveal differences between patients and control subjects. CONCLUSION: Signal abnormalities in the white matter of adolescents and young adults under diet control may be interpreted as consequence of structural alterations like dysmyelination. The reduced ADC and FA in the white matter with preserved MT indicate a reduction in fiber tracks.

An unusual manifestation of post-transplant lymphoproliferative disorder in the lip after pediatric heart transplantation.

PTLD is a serious and frequently observed complication after solid organ transplantation. We present a six-yr-old girl with a rapidly growing, solid tumor of the lip four yr after orthotopic heart transplantation, which was classified as monomorphic PTLD with the characteristics of a diffuse large B-cell lymphoma. Treatment with reduction in immunosuppression, ganciclovir, and anti B-cell monoclonal antibody (rituximab) resulted in full remission since 12 months. To the best of our knowledge, this report is the first description of PTLD in the lip in a pediatric patient after heart transplantation in the English literature.

Bloody nipple discharge (BND) in an 8 months old girl and a 9 months old male--rational diagnostic approach.

Bloody nipple discharge in adults is, in men as well as in women, often a symptom of an underlying malignant disease. In respect of this, multiple invasive and mutilating diagnostic procedures have been performed in infants and older children. Apart from individual cases in older and pubertal children, in childhood benign conditions are most common and can be diagnosed by non-invasive diagnostic procedures. Here we discuss a rational diagnostic approach on the basis of 2 patients with bloody nipple discharge at the age of 8 and 9 months which resolved spontaneously without treatment after 3 and 6 months, respectively.

[Evaluation of malformations of the fetal central nervous system using fetal MRI]. / Das fetale MRT in der pränatalen Beurteilung von ZNS-Störungen.

PURPOSE: Ultrasound as the primary prenatal screening modality is used to detect fetal anomalies. Aim of the study was to prove the additional value of fetal magnetic resonance imaging (MRI). MATERIALS AND METHODS: In 25 pregnant women (age 30.6 +/- 4.8; 24 single and one twin pregnancy) with pathologic findings of the central nervous system detected by obstetric ultrasound, a fetal MRI was performed. All sequences (T2w-HASTE, TRUEFISP, T 1w-FLASH 2D, DWI) were performed using the breath-hold technique. The results were compared to postnatal MRI or ultrasound scan findings and tested for correlation with the clinical course and development of these children. RESULTS: Three to seven days after ultrasound, an MRI of all 26 fetuses without sedation was performed (26.6 +/- 4.0 GW). One healthy twin was not included in this study. MRI confirmed the ultrasonographic diagnosis in 7 cases. Compared to ultrasound, an additional pathology could be detected by MRI in 8 cases. In 10 cases ultrasound diagnosis was overruled by MRI. Prenatal MRI findings were confirmed by postnatal imaging in 18 children. The clinical course was predictable in 8 of 15 cases, depending on the pathology detected. Three newborns died in the perinatal period. CONCLUSION: Our results showed that fetal MRI has a high impact as an addition to ultrasound in evaluating congenital CNS pathology. Fetal MRI has become a helpful device for advising parents. However, clinical course and development still cannot be predicted based on MRI findings alone.

Intracardiac erythropoietin injection reveals antiinflammatory potential and improved cardiac functions detected by Forced Swim Test.

Systemic administration of erythropoietin (Epo) protects the myocardium from an ischemic insult and promotes beneficial remodeling. We hypothesized that intracardiac injection of Epo may exhibit cardioprotective potential with reduced systemic toxicity. Following myocardial infarction (MI), Epo was injected directly into the border of the infarction. Six weeks after an MI, we evaluated infarction size, angiogenesis, and pathologic effects of the treatment. Myocardial performance was assessed with a Forced Swim Test adapted to the study. Anti-inflammatory and cellular proliferative effects of Epo were analyzed by measuring expression of integrin-beta and CdK4 by reverse transcriptase-polymerase chain reaction (RT-PCR). The findings indicated improved cardiac status with direct Epo administration. Exercise capacity detected by the Forced Swim Test was significantly increased. There was radical reduction of absolute infarction size, ventricular dilatation, and hypertrophy in the Epo group. Integrin-beta was down-regulated and CdK4 expression was increased significantly with Epo. In conclusion, the study demonstrated that intramyocardial Epo injection, following MI, reduced inflammation, enhanced angiogenesis and proliferation, improved myocardial functions, and did not lead to intramural thrombus formation.

Polyesteramide-derived nonwovens as innovative degradable matrices support preadipocyte adhesion, proliferation, and differentiation.

Extended soft tissue defects resulting from injuries or tumor resections are still an unresolved problem in plastic and reconstructive surgery because adequate reconstruction is difficult. Immature adipogenic precursor cells, called preadipocytes, which are located between mature adipocytes in adipose tissue, represent a powerful tool for soft tissue engineering because of their ability to proliferate and differentiate into adipose tissue after transplantation. In previous studies, we compared preadipocyte-loaded hyaluronan or collagen biomaterials and their applicability for adipose tissue engineering. Our findings demonstrated successful de novo formation of adipose tissue in vivo but pore size and stiffness were limiting factors not allowing for sufficient cell distribution in the construct. This study presents a nonwoven made of novel bioabsorbable co-poly(ester amide) based on e-caprolactam, adipic acid, and 1,4-butanediol in an innovative 3-dimensional architecture. The material was formed into nonwovens by textile manufacturing using an aerodynamic web formation process and a needle felting technique. Carriers were seeded with human preadipocytes and examined for cellular proliferation and differentiation. In addition, methods of preparing scaffolds for optimal cell interaction were evaluated. Our findings show that polyesteramide-derived nonwovens allow good adherence, proliferation, and differentiation of preadipocytes. These results are promising guidance toward an optimally designed scaffold for in vivo use.

Event-related potential correlates of mindfulness meditation competence.

OBJECTIVE: This cross-sectional study evaluated event-related potentials (ERPs) across three groups: naïve, novice, and experienced meditators as potential physiological markers of mindfulness meditation competence. METHODS: Electroencephalographic (EEG) data were collected during a target tone detection task and a Breath Counting task. The Breath Counting task served as the mindfulness meditation condition for the novice and experienced meditator groups. Participants were instructed to respond to target tones with a button press in the first task (Tones), and then ignore the primed tones while Breath Counting. The primary outcomes were ERP responses to target tones, namely the N2 and P3, as markers of stimulus discrimination and attention, respectively. RESULTS: As expected, P3 amplitudes elicited by target tones were attenuated within groups during the Breath Counting task in comparison to the Tones task (p<.001). There was a task by group interaction for P3 (p=.039). Both meditator groups displayed greater change in peak-to-trough P3 amplitudes, with higher amplitudes during the Tones condition and more pronounced reductions in P3 amplitudes during the Breath Counting meditation task in comparison to the naïve group. CONCLUSIONS: Meditators had stronger P3 amplitude responses to target tones when instructed to attend to the tones, and a greater attenuation of P3 amplitudes when instructed to ignore the same tones during the Breath Counting task. This study introduces the idea of identifying ERP markers as a means of measuring mindfulness meditation competence, and results suggest this may be a valid approach. This information has the potential to improve mindfulness meditation interventions by allowing objective assessment of mindfulness meditation quality.

L-arginine and arginine ethyl ester enhance proliferation of endothelial cells and preadipocytes - how an arginine ethyl ester-releasing biomaterial could support endothelial cell growth in tissue engineering.

Adipose tissue engineering is a promising solution for the reconstruction of soft tissue defects. An insufficient neovascularisation within the scaffolds that leads to necrosis and tissue loss is still a major shortcoming of current tissue engineering attempts. Biomaterials, which release angiogenic factors such as L-arginine, could overcome this challenge by supporting the neovascularisation of the constructs. L-arginine is insoluble in organic solvents and thus cannot be incorporated into commonly used polymers in contrast to its ethyl ester. Here, we compared the effects of arginine and its ethyl ester on endothelial cells and preadipocytes, and generated an arginine ethyl ester-releasing, angiogenic polymer. We cultivated adipose tissue-derived endothelial cells and preadipocytes in arginine-free medium supplemented with L-arginine or L-arginine ethyl ester and assayed the proliferation rate and the degree of adipogenic differentiation, respectively. Additionally, we prepared arginine ethyl ester-releasing poly(D,L-lactide) foils, and investigated their impact on endothelial cell proliferation. We could demonstrate that arginine ethyl ester like arginine significantly increased the proliferation of endothelial cells and preadipocytes without inhibiting an induced adipogenic conversion of the preadipocytes. Further, we could show that the arginine ethyl ester-releasing polymer significantly increased endothelial cell growth. The present data are helpful guidance for generating angiogenic biomaterials that promote endothelial cell growth, and thereby could support neovascularisation within tissue engineering approaches.

Bioactive immobilization of r-hirudin on CVD-coated metallic implant devices.

The poor biocompatibility of metallic coronary stents which leads to un-satisfying restenosis rates is mainly caused by contact activation of blood cells, smooth muscle cells and endothelial cells. Mimicking a metal surface with a biocompatible coating that actively suppresses mechanisms leading to restenosis may overcome today's limitations regarding the complications of metal stents. Nitinol coronary stents were coated by CVD polymerization of functionalized [2.2]paracyclophanes. The monomers 4-amino [2.2]paracyclophane, 4-hydroxy methyl [2.2]paracyclophane and [2.2]paracyclophane-4,5,12,13-tetracarboxylic acid dianhydride were previously synthesized. A suitable installation for the CVD polymerization procedure was designed and used for the polymerization procedures. Physical and chemical properties of the polymers were shown to fulfill the requirements regarding the application as a stent coating material. The functional groups of the polymer coatings were used for the immobilization of the thrombin inhibitor r-hirudin. In vitro results indicate that the bioactively coated stents are less thrombogenic than virgin metallic stents. Surface-bound r-hirudin decreases platelet adhesion drastically due to interactions between platelets and r-hirudin.

Plasma-induced surface modifications on silicone intraocular lenses: chemical analysis and in vitro characterization.

In contrast to the high standard of intraocular lens implantation today, lens fixation and the occurrence of secondary opacifications are still not satisfactory. We are working on an implant that builds a stable connection to the surrounding lens-capsule. Disc-shaped lenses made of poly(dimethylsiloxane) were treated with different kinds of plasma to bring functional groups to the surface. This allows further macromolecular coating. The results of the surface modifications were characterized by electron spectroscopy for chemical analysis, scanning electron microscopy, Fourier transform infrared spectroscopy and cell culture experiments. O2 plasma induces a rapid increase of functional groups on the lens surface. CO2 plasma has to be used for longer treatment periods to achieve the same increase, but as SEM shows, did not lead to surface damage up to periods of 300 s. Using O2 plasma for longer than 60 s, a crack formation occurred. Therefore, CO2 plasma may be a more effective and sensitive tool in grafting functional groups to the surface.

High density binding of proteins and peptides to poly(D,L-lactide) grafted with polyacrylic acid.

The use of graft polymers for the functionalisation of biomaterial surfaces is already widespread. We investigated the adsorptive and covalent binding of a variety of proteins and peptides to poly(D,L-lactide) grafted with polyacrylic acid. Covalent attachment was achieved through coupling of amino groups of the protein/peptide to the carboxyl groups of the graft polymer by using a water-soluble carbodiimide and N-hydroxysuccinimide. Binding densities were determined by automated amino acid analysis after acid hydrolysis of both the poly(D,L-lactide) and the adsorbed and covalently bound proteins. Experiments in the absence and presence of the coupling reagents allow to discriminate between adsorptive and covalent binding. Although the adsorptivc binding is quite substantial in absolute terms, the amount of adsorbed protein is relatively low as compared to the total amount of bound protein. Total binding densities of 20-30 microg/cm2 can easily be achieved. Depending on the concentration and on the properties of the proteins and peptides, between 5% and 80% of the totally bound protein may be physically adsorbed. Densities expressed in molecules/10 nm2 vary from 0.5 molecule fibronectin to 2,000 laminin-peptide molecules: their binding densities clearly correlate with their respective molecular masses. Obviously, the binding densities are governed by their individual three-dimensional space requirements rather than the density of the available carboxyl groups. From the number of carboxyl groups/10 nm2 (18,000-30,000 COOH/10 nm2) the average length of the acrylic acid graft polymer molecules was estimated. Based on the assumption that about 10 copolymer chains can be accommodated on 10 nm2, the average length of the polymer chains, which corresponds to the thickness of the graft phase, is estimated to be 0.5-1 microm. The organisation of the proteins and peptides within the polyacrylic acid phase was further investigated by experiments in which a protein (BSA) and a peptide (Val-Lys) were allowed to react in either a singular, a consecutive or a simultaneous way. Together with XPS and IR-ATR surface characterisation experiments a three-dimensional picture of the arrangement of the immobilised proteins and peptides within the graft polymer phase emerges.

Effect of biologically active coating on biocompatibility of Nitinol devices designed for the closure of intra-atrial communications.

Anti-thrombogenicity and rapid endothelialisation are prerequisites for the use of closure devices of intra-atrial communications in order to reduce the risk of cerebral embolism. The purpose of this study was therefore to assess the effect of bioactive coatings on biocompatibility of Nitinol coils designed for the closure of intra-atrial communications. Nitinol coils (n = 10, each) and flat Nitinol bands (n = 3, each) were treated by basic coating with poly(amino-p-xylylene-co-p-xylylene) and then coated with either heparin, r-hirudin or fibronectin. Anti-thrombogenicity was studied in vitro in a dynamic model with whole blood by partial thromboplastin time (PTT), platelet binding and thrombin generation, respectively, and cytotoxicity by hemolysis. Endothelialisation was studied on Nitinol bands with human umbilical venous endothelial cells (HUVEC) by 3-(4,5-dimethylthiazole-2yl)-2,5-triphenyl tetrazolium (MTT) assay and immnuofluorescence analysis of Ki67, vinculin, fibronectin and von Willebrand Factor. Uncoated or coated devices did not influence hemolysis and PTT. r-Hirudin (but not heparin) and fibronectin coating showed lower platelet binding than uncoated Nitinol (p < 0.005, respectively). Heparin and r-hirudin coating reduced thrombin formation (p < 0.05 versus Nitinol, respectively). HUVEC adhesion, proliferation, and matrix formation decreased in the order: fibronectin coating > uncoated Nitinol > r-hirudin coating > heparin coating > basic coating. MTT assay corroborated these findings. In conclusion, r-hirudin and fibronectin coating, by causing no acute cytotoxicity, decreasing thrombogenicity and increasing endothelialisation improve in vitro biocompatibility of Nitinol devices designed for the closure of intra-atrial communications.

Minimization of protein adsorption on poly(vinylidene fluoride).

Surfaces covered with polyethylene glycol (PEG) have been shown to be biocompatible because PEG yields nonimmunogenicity, nonantigenicity and protein rejection. To produce a biocompatible surface coating, we have developed a method for grafting PEG onto modified poly(vinylidene fluoride) (PVDF) films. The first step was to create carboxy groups on the PVDF surface following covalente coupling of polyethylenimine (PEI) to achieve high density of amino groups. These surface amines were reacted with formyl-terminated PEG's with various molecular weight. The modified PVDF surface was characterized by means of static contact angle measurements, infrared (IR) spectroscopy and X-ray photoelectron spectroscopy (XPS). The influence of the chain length on lysozyme repellence was investigated by means of surface-MALDI-Tof mass spectrometry (Surface-MALDI-Tof-MS). Lysozyme adsorption was significantly suppressed on the PEG 5000 modified PVDF surface.

Development and characterization of a wettable surface modified aromatic polyethersulphone using glow discharge induced HEMA-graft polymerisation.

The aromatic polyethersulphone (PES) is a well known polymer for the preparation of membranes with excellent thermal stability and chemical resistance. The disadvantage of PES-membranes is their hydrophobic character, which in contact with protein containing solutions leads to high protein adsorption and as a consequence to deterioration of membrane properties. In this report the surface modification of PES by means of glow discharge induced grafting of 2-hydroxyethyl methacrylate (HEMA) is described. Graft polymerisation creates a largely wettable layer of poly(2-hydroxyethyl methacrylate) (PHEMA) on the surface of PES. This has been shown by contact angle measurements using the Wilhelmy plate method. Chemical characterization is carried out by means of X-ray photoelectron spectroscopy (XPS) and infrared spectroscopy/attentuated total reflection (FTIR-ATR). The influence of storage conditions on the surface properties of modified PES samples has been investigated after storage in vacuum, water, and air.

Development of a biodegradable ureteric stent: surface modification and in vitro assessment.

The aim of the present study was to develop a short bioresorbable ureteric stent and to characterize the chosen polymers with respect to surface modification, biocompatibility, and loading of a biologically active compound. As materials for the stent, poly(D,L-lactide) and poly(D,L-lactide-co-glycolide) were chosen. Degradation experiments were carried out and analytical data were obtained by contact angle measurement, X-ray photoelectron spectroscopy (XPS), and infrared spectroscopy in the attenuated reflection mode (FTIR-ATR). Gas loading technology was used to incorporate biologically active compounds, and biocompatibility of the polymers was assessed by in vitro cellular assays, applying measures such as cell morphology, proliferative activity, and membrane integrity. Our results indicate that surface modification of bioresorbable polymers is a suitable and efficient approach to improve the surface properties. Incorporation of biologically active compounds was possible without loss of activity, and in vitro assessment of cellular responses demonstrated the biocompatibility of the chosen polymers and modifications.

[A novel hirudin coating of vascular endoprostheses: experimental results]. / Eine neuartige Hirudinbeschichtung vaskulärer Endoprothesen: Experimentelle Ergebnisse.

PURPOSE: Does hirudin coating improve the patency of iliac artery endoprostheses in comparison to non-hirudin-coated endoprostheses? MATERIALS AND METHODS: Nitinol stents and stentgrafts covered with polytetrafluoroethylene (PTFE) were coated with the polymer polyamino-p-xylylene-co-poly-p-xylylene using chemical vapor deposition (CVD) technique. Hirudin was covalently bound to the surface of the endoprostheses via the amino-group. External factors (mounting of the prosthesis, sterilization, storage time and temperature, release) affecting the hirudin activity were evaluated in vitro. Five types of prostheses were compared in vivo: (1) plain and (2) CVD- and hirudin-coated stents; (3) plain, (4) CVD-coated, and (5) CVD- and hirudin-coated PTFE-stentgrafts. In 20 sheep, 16 protheses of each type were inserted in arteries pretreated with a Fogarty maneuver. The animals were followed for either 1 (n = 10) or 6 (n = 10) months. Immediately after implantation and after 1, 3, and 6 months, intravascular ultrasound (IVUS) and angiography were performed. The vascular specimens were analyzed histologically. RESULTS: Within 10 weeks, the hirudin activity of coated stents dropped 60 % due to external factors; the activity of coated PTFE stentgrafts dropped 20 %. After 1, 3, and 6 months, IVUS and histology revealed a significantly reduced patency of the hirudin-coated stentgrafts compared to the other prostheses. Only IVUS showed a significantly reduced patency of hirudin coated stents after 1 and 3 months compared to plain and CVD-coated PTFE-stentgrafts. The reduced patency was caused by neointimal hyperplasia. CONCLUSIONS: In an experimental setting, hirudin coating did not improve the patency of vascular endoprostheses.

Infective endocarditis due to Fusobacterium nucleatum: case report and review of the literature.

Endocarditis caused by Fusobacterium nucleatum is exceedingly rare. We report a case of F. nucleatum right-sided endocarditis in a patient with no known intravenous drug abuse. A detailed computer and manual search of the literature using Med-Line and Index Medicus, respectively, revealed a total of five cases of endocarditis due to this species. The clinical characteristics and the patient's hospital course are summarized and reviewed.