Carotid endarterectomy in patients with foetal-type posterior circle of Willis: is there an indication for local anaesthesia?

Foetal-type posterior circle of Willis is a common anatomical variation with a variable degree of vessel asymmetry. In patients with this abnormality, carotid endarterectomy (CEA) may create cerebral hypo-perfusion intraoperatively, and this may be underestimated under general anaesthesia. There is currently no evidence that anatomical variations in the circle of Willis represent an independent risk factor for stroke. Moreover, there is a paucity of data on treating patients with such anatomical variations and co-existing ICA stenosis. We present a case of CEA under local anaesthesia (LA) in a 52-year-old female patient with symptomatic stenosis of the right ICA and coexistent foetal-type posterior circle of Willis. There were no post-operative complications and she was discharged free from symptoms. She was seen again 3 months later and was free from complications. This case higlights that LA should be strongly considered to enable better intra-operative neurological monitoring in the event of foetal-type posterior circle of Willis.

erg, a human ets-related gene on chromosome 21: alternative splicing, polyadenylation, and translation.

The avian acute leukemia virus E26 induces a mixed erythroid-myeloid leukemia in chickens and carries two distinct oncogenes, v-myb and v-ets. Recently, a novel gene named erg, closely related to the v-ets oncogene, was identified in human COLO 320 cells and the nucleotide sequence of its approximately 5.0-kilobase transcript, erg 1 was determined. In the present study, the nucleotide sequence of the alternatively spliced transcript, erg 2, was found to differ from erg 1 by a splicing event that causes a coding frameshift near the amino terminus, resulting in an additional 99-amino acid insertion at the amino-terminus. Expression of complementary DNAs for the two transcripts in vitro resulted in synthesis of polypeptides of approximately 41 and 52 kilodaltons, suggesting the use of alternative translation initiation codons in the case of erg proteins. The erg gene was localized by somatic cell genetic analysis to human chromosome 21. It is proposed that alternative sites of splicing and polyadenylation, together with alternative sites of translation initiation, allow the synthesis of two related polypeptides from a single erg gene transcriptional unit.

High-level expression in Escherichia coli of enzymatically active Harvey murine sarcoma virus p21ras protein.

The gene for the Harvey murine sarcoma virus (Ha-MuSV) p21ras protein was fused to the amino-terminal portion of the bacteriophage lambda cII gene on the expression vector pJL6. The fusion was such that transcription was controlled by the well-regulated phage lambda pL promoter, and translation initiated in the cII gene continued in frame into the ras gene sequences that code for p21. When the pL promoter was derepressed, the Escherichia coli cells harboring the fusion plasmid synthesized 23,000-dalton protein, which represented more than 10 percent of the total cellular protein. This protein was chimeric and contained 14 residues, which were specified by the vector; these residues were followed by all of the amino acids that make up Ha-MuSV p21ras except for four residues at the amino-terminal end. The protein appears similar to Ha-MuSV p21ras in that it undergoes immunoprecipitation by monoclonal antibodies directed toward that protein, binds guanosine diphosphate, and is capable of autophosphorylation.

Identification of HTLV-III/LAV sor gene product and detection of antibodies in human sera.

The nucleotide sequence of the genome of HTLV-III, the infectious agent etiologically associated with the acquired immune deficiency syndrome, predicts a small open reading frame, termed sor, located between the pol and env genes. A DNA segment containing 82 percent of the sor region was inserted into a prokaryotic expression vector, pJL6, to determine whether sor encodes a viral protein and to gain some insight into its possible function. The bacterially synthesized sor protein reacted with sera from individuals infected with HTLV-III, indicating that sor is expressed as a protein product or products that are immunogenic in vivo. Antibodies to the purified, bacterially synthesized sor protein were found to react specifically with the same protein and also with a protein of molecular weight 23,000 (23K) in HTLV-III-infected H9 cell extracts. The 23K protein comigrated with a protein immunoprecipitated by the serum of a hemophiliac patient with antibodies to HTLV-III, suggesting that this protein is probably the sor gene product.

Diagnostic potential for human malignancies of bacterially produced HTLV-I envelope protein.

Two regions of the gene for the human T-cell leukemia virus subgroup I (HTLV-I) envelope were expressed in Escherichia coli by use of the vector pJLA16. One corresponds to the carboxyl terminal region of the major envelope protein p46, and the other corresponds to the transmembrane protein p21E. Reactivity of the expressed protein with human serum was tested by the Western blot procedure. Each of 11 sera tested that had been shown to contain antibodies to HTLV-I or HTLV-II by an enzyme-linked immunosorbent assay recognized the bacterially synthesized envelope proteins. There was no reaction detected when 17 control sera were tested. This system will be useful for large-scale seroepidemiological surveys for HTLV-I and related human retroviruses.

A common onc gene sequence transduced by avian carcinoma virus MH2 and by murine sarcoma virus 3611.

A common cellular sequence was independently transduced by avian carcinoma virus MH2 (v-mht) and murine sarcoma virus (MSV) 3611 (v-raf). Comparison of the nucleotide sequences of v-mht and v-raf revealed a region of homology that extends over 969 nucleotides. The homology between the corresponding amino acids was about 95 percent with only 19 of 323 amino acids being different. With this example, 5 of the 19 known different viral onc genes have been observed in viruses of different taxonomic groups. These data indicate that (i) the number of cellular proto-onc genes is limited because, like other viruses of different taxonomic groups, MH2 and MSV 3611 have transduced the same onc gene-specific sequences from different cell species and (ii) that specific deletion and linkage of the same proto-onc sequences to different viral vector elements affect the oncogenic potential of the resulting viruses. The difference in transformation capabilities of MH2 and MSV 3611 serves as an example.

Requirement of ets-2 expression for Xenopus oocyte maturation.

A molecular clone of the Xenopus laevis ets-2 gene was isolated from an oocyte complementary DNA library. The amount of messenger RNA (mRNA) in each oocyte or embryo was almost constant during oogenesis and was maintained until the blastula stage of embryonic development, indicating that the observed 3.2-kilobase transcript is a maternal message. The only normal adult tissue in which ets-2 mRNA was detected was the ovary. Injection of antisense oligonucleotides homologous to the ets-2 sequence into oocytes led to degradation of the mRNA and blocked hormone-induced germinal vesicle breakdown. The ets-2 product is thus required for the meiotic maturation of Xenopus oocytes.

Sequence-specific binding of human Ets-1 to the T cell receptor alpha gene enhancer.

Expression of the human T cell receptor (TCR) alpha gene is regulated by a T cell-specific transcriptional enhancer that is located 4.5 kilobases (kb) 3' to the C alpha gene segment. The core enhancer contains two nuclear protein binding sites, T alpha 1 and T alpha 2, which are essential for full enhancer activity. T alpha 1 contains a consensus cyclic adenosine monophosphate (cAMP) response element (CRE) and binds a set of ubiquitously expressed CRE binding proteins. In contrast, the transcription factors that interact with the T alpha 2 site have not been defined. In this report, a lambda gt11 expression protocol was used to isolate a complementary DNA (cDNA) that programs the expression of a T alpha 2 binding protein. DNA sequence analysis demonstrated that this clone encodes the human ets-1 proto-oncogene. Lysogen extracts produced with this cDNA clone contained a beta-galactosidase-Ets-1 fusion protein that bound specifically to a synthetic T alpha 2 oligonucleotide. The Ets-1 binding site was localized to a 17-base pair (bp) region from the 3' end of T alpha 2. Mutation of five nucleotides within this sequence abolished both Ets-1 binding and the activity of the TCR alpha enhancer in T cells. These results demonstrate that Ets-1 binds in a sequence-specific fashion to the human TCR alpha enhancer and suggest that this developmentally regulated proto-oncogene functions in regulating TCR alpha gene expression.

Nucleotide sequence of the transforming gene of avian myeloblastosis virus.

Avian myeloblastosis virus is defective in reproductive capacity, requiring a helper virus to provide the viral proteins essential for synthesis of new infectious virus. This virus arose by recombination of the nondefective helper virus and host cellular sequences present within the normal avian genome. These latter sequences are essential for leukemogenic activity. The complete nucleotide sequence of this region is reported. Within the acquired cellular sequences there is an open reading frame of 795 nucleotides starting with the initiation codon ATG (adenine, thymine, guanine) and terminating with the triplet TAG. This open reading frame could code for the putative transforming protein of 265 amino acids with a molecular weight of approximately 30,000.

Hu-ets-1 and Hu-ets-2 genes are transposed in acute leukemias with (4;11) and (8;21) translocations.

Human probes identifying the cellular homologs of the v-ets gene, Hu-ets-1 and Hu-ets-2, and two panels of rodent-human cell hybrids were used to study specific translocations occurring in acute leukemias. The human ets-1 gene was found to translocate from chromosome 11 to 4 in the t(4;11)(q21;23), a translocation characteristic of a subtype of leukemia that represents the expansion of a myeloid/lymphoid precursor cell. Similarly, the human ets-2 gene was found to translocate from chromosome 21 to chromosome 8 in the t(8;21)(q22;q22), a nonrandom translocation commonly found in patients with acute myeloid leukemia with morphology M2 (AML-M2). Both translocations are associated with expression different from the expression in normal lymphoid cells of ets genes, raising the possibility that these genes play a role in the pathogenesis of these leukemias.

Phosphorylation of the ETS-2 protein: regulation by the T-cell antigen receptor-CD3 complex.

Phosphorylation of the human ets-2 protein in response to mitogenic signals to T lymphocytes was investigated in Jurkat cells. Activation of the cells by antibodies against the T-cell antigen receptor-CD3 complex or by concanavalin A was followed within 5 min by increased phosphorylation of the protein, as shown by a mobility shift of the protein from 54 to 56 kilodaltons in sodium dodecyl sulfate-polyacrylamide gel electrophoresis and increased incorporation of 32P. The Ca2+ ionophores A23187 and ionomycin were able to mimic this effect, suggesting that this phosphorylation is mediated by Ca2+.

c-myc can induce expression of G0/G1 transition genes.

The human c-myc oncogene was linked to the heat shock-inducible Drosophila hsp70 promoter and used to stably transfect mouse BALB/c 3T3 cells. Heat shock of the transfectants at 42 degrees C followed by recovery at 37 degrees C resulted in the appearance of the human c-myc protein which was appropriately localized to the nuclear fraction. Two-dimensional analysis of the proteins of density-arrested cells which had been heat shock treated revealed the induction of eight protein species and the repression of five protein species. All of the induced and repressed proteins were nonabundant. cDNA clones corresponding to genes induced during the G0/G1 transition were used as probes to assay for c-myc inducibility of these genes. Two anonymous sequences previously identified as serum inducible (3CH77 and 3CH92) were induced when c-myc was expressed. In response to serum stimulation, 3CH77 and 3CH92 were expressed before c-myc mRNA levels increased. However, in response to specific induction of c-myc by heat shock of serum arrested cells, 3CH77 and 3CH92 mRNA levels increased after the rise in c-myc mRNA. Therefore, we hypothesize that abnormal expression of c-myc can induce genes involved in the proliferative response.

A short-lived nuclear phosphoprotein encoded by the human ets-2 proto-oncogene is stabilized by activation of protein kinase C.

The human ets-2 gene is a homolog of the v-ets oncogene of the E26 virus and codes for a 56-kilodalton nuclear protein. The ets-2 protein is phosphorylated and has a rapid turnover, with a half-life of 20 min. When human lymphocytic CEM cells were treated with the tumor promoter 12-O-tetradecanoylphorbol-13-acetate (TPA), the level of the ets-2 protein was quickly elevated 5- to 20-fold. This effect of TPA was mimicked by a synthetic diacylglycerol, 1-oleoyl-2-acetyl glycerol, and was blocked by the protein kinase C inhibitor H7, indicating that protein kinase C is involved in the induction. The increase in the ets-2 protein was due to stabilization of the protein, because the protein had a half-life of more than 2 h in the presence of TPA and the ets-2 mRNA level did not increase significantly upon TPA treatment. The protein synthesis inhibitor cycloheximide enhanced the effect of TPA on the ets-2 protein and could itself slow turnover of the protein. Properties of the ets-2 protein, such as nuclear localization, phosphorylation, rapid turnover, and response to protein kinase C, indicate that this protein belongs to a group of oncogene proteins which are generally thought to have regulatory functions in the nucleus (e.g., myc, fos, myb, and p53). Our results suggest that protein kinase C, either directly or indirectly, regulates the level of the ets-2 protein by posttranslational mechanisms.

Hemorrhage, impaired hematopoiesis, and lethality in mouse embryos carrying a targeted disruption of the Fli1 transcription factor.

The Ets family of transcription factors have been suggested to function as key regulators of hematopoeisis. Here we describe aberrant hematopoeisis and hemorrhaging in mouse embryos homozygous for a targeted disruption in the Ets family member, Fli1. Mutant embryos are found to hemorrhage from the dorsal aorta to the lumen of the neural tube and ventricles of the brain (hematorrhachis) on embryonic day 11.0 (E11.0) and are dead by E12.5. Histological examinations and in situ hybridization reveal disorganization of columnar epithelium and the presence of hematomas within the neuroepithelium and disruption of the basement membrane lying between this and mesenchymal tissues, both of which express Fli1 at the time of hemorrhaging. Livers from mutant embryos contain few pronormoblasts and basophilic normoblasts and have drastically reduced numbers of colony forming cells. These defects occur with complete penetrance of phenotype regardless of the genetic background (inbred B6, hybrid 129/B6, or outbred CD1) or the targeted embryonic stem cell line used for the generation of knockout lines. Taken together, these results provide in vivo evidence for the role of Fli1 in the regulation of hematopoiesis and hemostasis.

Changes in blood flow of anterior and middle cerebral arteries following carotid endarterectomy: a transcranial Doppler study.

AIM: The aim of the present study was to evaluate the changes in blood flow of anterior and middle cerebral arteries following carotid endarterectomy, using transcranial Doppler (TCD) flow studies. PATIENTS AND METHODS: This study included 100 patients (72 men, mean age 65 years) who underwent carotid endarterectomy because of high-grade carotid stenosis or symptoms of ischemic stroke. Endarterectomy was performed by a distal shunt between the common carotid and internal carotid arteries. Blood flow in the anterior and middle cerebral arteries was assessed by TCD preoperatively and also in the postoperative period (1st and 4th day; 1st, 6th, and 12th month). Collateral circulation in the Willis circle was evaluated by common carotid compression. RESULTS: Patients with bilateral carotid stenosis > or =70% exhibited a significantly increased flow velocity in the ipsilateral anterior cerebral artery (ACA), middle cerebral artery (MCA), and in the contralateral ACA. Patients with entirely occluded contralateral internal carotid artery showed the most pronounced changes in cerebral hemodynamics. Blood flow velocities returned to the preoperative values at 1 to 12 months following endarterectomy. Hyperperfusion syndrome was manifested in 14 patients, who exhibited significantly higher flow velocities in the ipsilateral MCA compared with asymptomatic patients. CONCLUSIONS: A transient bilateral increase of blood flow velocity in the anterior part of the Willis circle may often occur in the immediate postoperative period following carotid endarterectomy. Although its clinical significance is not entirely understood, this increase may be associated with cerebral hyperperfusion syndrome.

Lower extremity compartment sindrome following coronary artery bypass.

Compartment syndrome is a constellation of symptoms and signs associated with abnormally elevated tissue pressure in the skeletal muscle of the extremities. It is manifested in anatomic locations where muscles are enveloped in fasciae. The case of a lower extremity compartment syndrome in a 71-year-old male patient who underwent coronary artery bypass grafting (CABG) and simultaneous aortic valve surgery is reported. Preoperative evaluation revealed severe peripheral vascular disease. The patient underwent triple CABG using the left internal thoracic artery and two vein grafts. The right great saphenous vein was used for these vein grafts. The aortic valve was replaced with a biologic prosthesis. On postoperative day 1, the patient complained of pain and oedema in the right calf. The next day, symptoms worsened, with marked sensory loss, motor weakness and foot drop in the affected limb. Triplex ultrasonography excluded deep vein thrombosis. Compartment syndrome was diagnosed and successfully managed by fasciotomy. This case illustrates that compartment syndrome may, although rarely, be a complication of CABG.

Ankle-brachial index: a surrogate marker of microvascular complications in type 2 diabetes mellitus?

AIM: The aim of this study was to investigate the potential role of ankle-brachial index (ABI) as a marker of microvascular disease in patients with type 2 diabetes mellitus. METHODS: This study included 126 type 2 diabetic patients (64 male and 62 female) with an age of 66.6+/-5.3 years (mean+/-SD) and diabetes duration of 13.2+/-4.1 years. ABI was measured with a Doppler device. The exclusion criterion was the medial arterial calcification. Patients were also examined for microalbuminuria, retinopathy and peripheral neuropathy. RESULTS: ABI was significantly lower in patients with microalbuminuria than in those without microalbuminuria (0.91+/-0.17 vs 1.05+/-0.13, P=0.004), in patients with retinopathy than in those without retinopathy (0.91+/-0.18 vs 1.06+/-0.1, P=0.005), as well as in patients with neuropathy than in those without neuropathy (0.94+/-0.17 vs 1.06+/-0.11, P=0.001). Sensitivity and specificity of ABI <0.9 were 48.8% and 87.9% respectively for microalbuminuria, 39.1% and 93% respectively for retinopathy and 47% and 90.7% respectively for neuropathy. In multiple regression analysis, significant predictor of microalbuminuria was diabetes duration (P=0.0014), significant predictor of retinopathy was diabetes duration (P=0.001), while significant predictors of neuropathy were diabetes duration (P=0.001), male sex (P=0.001) and presence of retinopathy (P=0.047). CONCLUSION: ABI is significantly lower in patients with than in those without microvascular complications of type 2 diabetes. An ABI <0.9 has a low to modest sensitivity, but a high specificity for the diagnosis of these complications. Our results suggest a potential role for ABI as a surrogate marker of microvascular complications in type 2 diabetic patients.

Popliteal artery pseudoaneurysm after total knee replacement.

We report the case of a popliteal pseudoaneurysm following total knee replacement. A 70-year-old woman underwent total left knee replacement because of severe osteoarthritis. Eight days later she presented with oedema and pain in her left calf She had palpable foot pulses on the left leg and the ankle-brachial index was 0.98. The patient was treated for deep vein thrombosis. Two days later her calf pain and oedema deteriorated and her distal pulses were no longer palpable, while she developed limb coldness and paraesthesia, and the ankle-brachial index dropped to 0.4. Sonography was urgently performed indicating a large popliteal artery aneurysm (5.8 x 6.9 x 7.2 cm), confirmed by angiography. The patient was managed with removal of a 3.5 cm long segment of the popliteal artery and reconstruction with synthetic graft (PTFE 6 mm). Her condition soon improved and the patient is capable of walking approximately 1 km per day at 18-month follow-up.

Diagnostic criteria and treatment of Buerger's disease: a review.

Buerger's disease is an inflammatory occlusive disorder affecting the small and medium-size arteries and veins of young, predominantly male, smokers. The disorder has been identified as an autoimmune response triggered when nicotine is present. Tobacco abuse is the major contributing risk factor; however, smoking seems to be a synergistic factor rather than the cause of the disease. The traditional diagnosis of Buerger's disease is based on 5 criteria (smoking history, onset before the age of 50 years, infrapopliteal arterial occlusive disease, either upper limb involvement or phlebitis migrans, and absence of atherosclerotic risk factors other than smoking). As there is no specific diagnostic test and an absence of positive serologic markers, confident clinical diagnosis should be made only when all these 5 criteria have been fulfilled although not universally accepted. The angiographic findings in Buerger's disease ("corkscrew," "spider legs," or "tree roots") are helpful but not pathognomonic. A wide spectrum of medical or surgical therapeutic options have been proposed; however, total abstinence from tobacco use remains the only means of stopping the disease progression. The initial management of patients with Buerger's disease should be conservative. Because several arteries may be unaffected, claudicants should be encouraged to walk, whereas patients with "critical" ischemia should be admitted for bed rest in the hospital. Bypass grafting is seldom an option, as the location of the lesions distally leaves little to bypass because of lack of target vessels. A literature review revealed only a few series reporting vascular reconstruction (mainly femorodistal bypasses) in Buerger's disease. Bypass patency rates were suboptimal; however, the corresponding limb salvage rates were satisfactory. A possible explanation is that patent grafts, even over a short period of time, are sufficient to allow healing of ulcers in patients with Buerger's disease.

Isolation of antibodies specific for avian viral and cellular myc proteins.

The myc gene has been implicated in the genesis of various neoplasms in birds, mice, and humans and was originally identified as the cellular homologue of the transforming gene (v-myc) of the avian myelocytomatosis virus MC29. For specific antisera to be obtained for the myc gene product, a bacterial expression vector was constructed in which the coding sequences for approximately 20 kd of MC29 p110gag-myc (amino acid residues 502 to 678) were placed between the coding sequences for the amino terminal 13 kd of Rous sarcoma virus pp60src and the coding sequences for 112 kd of beta-galactosidase. Expression of this tripartite gene was driven by a hybrid trp-lac promoter under lac repressor control. Induction of expression resulted in the production of a 145-kd hybrid protein containing src, myc, and beta-galactosidase sequences. The hybrid protein was purified and injected into rabbits to produce antisera. The resultant antisera immunoprecipitated p110gag-myc and p58myc -p60myc from MC29- and MH2-infected nonproducer quail fibroblasts, respectively. In addition, the antisera also immunoprecipitated a 58-kd protein from the bursal lymphoma cell line BK25, which was identified as chicken c (cellular)-myc gene product.