MT1 and MT2 melatonin receptors play opposite roles in brain cancer progression.

Primary brain tumors remain among the deadliest of all cancers. Glioma grade IV (glioblastoma), the most common and malignant type of brain cancer, is associated with a 5-year survival rate of < 5%. Melatonin has been widely reported as an anticancer molecule, and we have recently demonstrated that the ability of gliomas to synthesize and accumulate this indolamine in the surrounding microenvironment negatively correlates with tumor malignancy. However, our understanding of the specific effects mediated through the activation of melatonin membrane receptors remains limited. Thus, here we investigated the specific roles of MT1 and MT2 in gliomas and medulloblastomas. Using the MT2 antagonist DH97, we showed that MT1 activation has a negative impact on the proliferation of human glioma and medulloblastoma cell lines, while MT2 activation has an opposite effect. Accordingly, gliomas have a decreased mRNA expression of MT1 (also known as MTNR1A) and an increased mRNA expression of MT2 (also known as MTNR1B) compared to the normal brain cortex. The MT1/MT2 expression ratio negatively correlates with the expression of cell cycle-related genes and is a positive prognostic factor in gliomas. Notably, we showed that functional selective drugs that simultaneously activate MT1 and inhibit MT2 exert robust anti-tumor effects in vitro and in vivo, downregulating the expression of cell cycle and energy metabolism genes in glioma stem-like cells. Overall, we provided the first evidence regarding the differential roles of MT1 and MT2 in brain tumor progression, highlighting their relevance as druggable targets. KEY MESSAGES: • MT1 impairs while MT2 promotes the proliferation of glioma and medulloblastoma cell lines. • Gliomas have a decreased expression of MT1 and an increased expression of MT2 compared to normal brain cortex. • Tumors with a high MT1/MT2 expression ratio have significantly better survival rates. • Functional selective drugs that simultaneously activate MT1 and inhibit MT2 downregulate the expression of cell cycle and energy metabolism genes in glioma stem-like cells and exert robust anti-tumor effects in vivo.

Energy Thresholds of DNA Damage Induced by UV Radiation: An XPS Study.

This work stresses on damage at the molecular level caused by ultraviolet radiation (UV) in the range from 3.5 to 8 eV, deoxyribonucleic acid (DNA) films observed by X-ray photoelectron spectroscopy (XPS). Detailed quantitative XPS analysis, in which all the amounts are relative to sodium-assumed not to be released from the samples, of the carbon, oxygen, and particularly, nitrogen components, reveals that irradiation leads to sugar degradation with CO-based compounds release for energies above 6.9 eV and decrease of nitrogen groups which are not involved in hydrogen bonding at energies above 4.2 eV. Also the phosphate groups are seen to decrease to energies above 4.2 eV. Analysis of XPS spectra allowed to conclude that the damage on bases peripheral nitrogen atoms are following the damage on phosphates. It suggests that very low kinetic energy photoelectrons are ejected from the DNA bases, as a result of UV light induced breaking of the phosphate ester groups which forms a transient anion with resonance formation and whereby most of the nitrogen DNA peripheral groups are removed. The degree of ionization of DNA was observed to increase with radiation energy, indicating that the ionized phosphate groups are kept unchanged. This result was interpreted by the shielding of phosphate groups caused by water molecules hydration near sodium atoms.

Influência do tempo de transporte para juvenis de pacamã (Lophiosilurus alexandri) / Influence of transport time on pacama juveniles (Lophiosilurus alexandri)

The aim of this work was to evaluate different transport times for pacama juvenile (Lophiosilurus alexandri) previously trained to feed formulated diets. Four hundred and eighty-six pacama juveniles (2.52±0.71g) were submitted to 24 hours of fasting before transport. The animals were divided into nine plastic bags, with density of 54 juveniles in 5L of clean water for each bag after that inflated with pure oxygen and then sealed. Fish were transported for three hours and bags were open at 5, 6 and 7.5 hours after closing. For each time three replications were used. Survival was monitored for 96 hours post-transport. The longest time tested showed the lowest values of dissolved oxygen and pH, while the total ammonia was similar in the different treatments. Survival was 100% for different transport times after 96 hours. Some juveniles returned to feed 48 hours and the majority 72 hours after opening the bags, suggesting the efficiency of transport made at different times.

Efeito dos níveis de energia para poedeiras comerciais no período final de produção sobre o desempenho, a conversão alimentar e energética e a qualidade de ovos / Effect of energy levels for old layers on performance, feed and energy conversion ratios and egg quality

Foram utilizadas 1200 poedeiras comerciais da linhagem Lohmann LSL, com 64 semanas, em gaiolas convencionais. Estas foram divididas em cinco grupos, de acordo com o nível de energia metabolizável aparente corrigida pelo nitrogênio (EMAn) presente em sua dieta: 2700kcal/kg; 2775kcal/kg; 2850kcal/kg; 2925kcal/kg; e 3000kcal/kg, com seis repetições. As aves receberam as rações, á base de milho e farelo de soja, por 16 semanas. O delineamento experimental foi inteiramente ao acaso, e as médias foram submetidas à regressão polinomial e ao teste de Kruskal-Wallis. O aumento de EMAn não exerceu efeito sobre a produção, a massa e o peso de ovos, bem como sobre o peso das aves e a viabilidade. O consumo de ração diminuiu de acordo com o aumento na energia da dieta, porém a conversão energética foi pior com esse aumento. Em contrapartida, a conversão alimentar melhorou o aumento dos níveis de EMAn. O consumo de EMAn é constante independentemente do seu nível dietético. Não há diferença nas unidades Haugh, nos sólidos da gema e na porcentagem dos componentes do ovo. O peso específico melhora com o aumento dos níveis de EMAn. Os níveis nutricionais para poedeiras velhas podem estar sendo superestimados.

A total of 1200 Lohmann LSL laying hens, with 64 weeks of age in conventional cages was used. These were divided into five groups according to the level of apparent metabolizable energy corrected for nitrogen retention (AMEn) present in the diet: 2700kcal/kg; 2775kcal/kg; 2850kcal/kg; 2925kcal/kg and 3000kcal/kg, with six replicates. The birds received the diets based on corn and soybean meal for 16 weeks. The experimental design was completely randomized and the means were submitted to polynomial regression and the Kruskal-Wallis test. The increased level of AMEn had no effect on production, egg mass and weight. There was no influence of AMEn on bird weight, egg weight and viability. Feed intake decreased with increasing levels, however, and the conversion of AMEn was worse with its increase, and in return feed conversion worsened with increasing consumption. AMEn is constant regardless of the level of the feed. There is no difference in Haugh units, yolk solids and percentage of egg components. The specific gravity improves with increasing levels of AMEn. The nutritional levels for older laying hens may be overestimated.

Performance and nutrient utilization in South American juvenile catfish Pseudoplatystoma spp. weighting 89 - 170g, fed at different energy and protein levels / Desempenho e utilização de nutrientes em juvenis de surubim Pseudoplatystoma spp. alimentados com diferentes níveis de energia e proteína

Most studies in nutrition for the South American catfish (surubim) were limited to the initial phase of development. However, it is clear that performance and nutrient utilization can change during the life stages of a fish. Therefore, this study aimed to evaluate the performance and nutrient utilization in juveniles of surubim fed diets varying in protein and energy levels. Two experiments were performed to test different levels of energy and protein in formulated diets. In the first experiment, surubim juveniles (89.2±4.8g) were fed five diets containing different levels of energy (18.0, 18.8, 19.6, 20.5, 21.3 MJ/kg). In the second experiment, juveniles (170.03±3.35g) were fed five diets containing different levels of protein (360, 400, 440, 480 and 520g/kg). The most favorable energy level for weight gain was 20.3 MJ/kg. The increasing energy levels provided a rise in fat and decrease in protein whole-body composition. The protein amount was between 360 to 400g/kg (383g/kg), which was adequate for performance and nutrient assimilation in surubim juveniles.

A maior parte dos estudos a respeito dos aspectos nutricionais do surubim está limitada às primeiras fases de desenvolvimento. Entretanto, é claro que o desempenho e a utilização dos nutrientes podem mudar durante os diferentes estágios de desenvolvimento destes animais. Assim sendo, este estudo teve como objetivo avaliar o desempenho e a utilização de nutrientes em juvenis de surubim alimentados com dietas contendo níveis variáveis de energia e proteína. Dois experimentos foram realizados para testar os diferentes níveis de proteína e energia. No primeiro experimento, juvenis de surubim (89,2±4,8g) foram alimentados com cinco dietas contendo níveis diferentes de energia (18.0, 18.8, 19.6, 20.5, 21.3MJ/kg). No segundo experimento, os juvenis (170,03±3,35g) foram alimentados com dietas contendo cinco níveis de proteína (360, 400, 440, 480 e 520g/kg). O melhor nível de energia para ganho de peso foi 20,3 MJ/kg. O aumento dos níveis de energia levou a um incremento nos níveis de lipídeo e diminuição da proteína corporal. Níveis de proteína entre 360 a 400g/kg foram os mais adequados para o desempenho e utilização dos nutrientes em juvenis grandes de surubim.

Determination of degree of ionization of poly(allylamine hydrochloride) (PAH) and poly[1-[4-(3-carboxy-4 hydroxyphenylazo)benzene sulfonamido]-1,2-ethanediyl, sodium salt] (PAZO) in layer-by-layer films using vacuum photoabsorption spectroscopy.

Electrostatic and hydrophobic interactions govern most of the properties of supramolecular systems, which is the reason determining the degree of ionization of macromolecules has become crucial for many applications. In this paper, we show that high-resolution ultraviolet spectroscopy (VUV) can be used to determine the degree of ionization and its effect on the electronic excitation energies of layer-by-layer (LbL) films of poly(allylamine hydrochloride) (PAH) and poly[1-[4-(3-carboxy-4 hydroxyphenylazo)benzene sulfonamido]-1,2-ethanediyl, sodium salt] (PAZO). A full assignment of the VUV peaks of these polyelectrolytes in solution and in cast or LbL films could be made, with their pH dependence allowing us to determine the pK(a) using the Henderson-Hasselbach equation. The pK(a) for PAZO increased from ca. 6 in solution to ca. 7.3 in LbL films owing to the charge transfer from PAH. Significantly, even using solutions at a fixed pH for PAH, the amount adsorbed on the LbL films still varied with the pH of the PAZO solutions due to these molecular-level interactions. Therefore, the procedure based on a comparison of VUV spectra from solutions and films obtained under distinct conditions is useful to determine the degree of dissociation of macromolecules, in addition to permitting interrogation of interface effects in multilayer films.

[A rich and blessed professional illness - organizing pneumonia due to gold dust]. / Uma doença profissional valiosa e abençoada - pneumonia organizativa devido a poeira de ouro.

A 47-year-old man, restorer of religious art, presents a three week history of asthenia, myalgia, dry cough and fever, coinciding with recent, unprotected exposure, to golden dust. He had fever, crackles in lung bases, hypoxemia and elevation of inflammatory markers. Imaging studies showed areas of parenchymal consolidation with air bronchograms in posterior-basal regions of both lungs, suggesting a pneumonic process. Lung function tests: mild restrictive pattern. Bronchoalveolar lavage: lymphocytosis with low CD4/CD8 ratio. Lung biopsy: intraalveolar pneumonia with exsudative process and organization. Treatment with Prednisolone 40mg id was started with excellent response. First month follow-up CT scan showed areas of ground glass suggesting residual pneumonitis, and he resumed normal activities with excellent exercise tolerance, under appropriate protection measures.

Long-term clinical results after stent implantation in old obstructed saphenous vein grafts.

STUDY OBJECTIVE: To assess the long-term clinical outcome of treating patients with coronary artery disease and obstructed saphenous vein grafts (SVGs) with stents deployed by oversized balloon catheters. DESIGN: The study included 89 of 92 consecutive patients who had 121 SVG stent implants (average, 1.4 stents per patient). We aimed at achieving a negative stenosis using oversized balloons to achieve a catheter to artery ratio of 1.1:1, and a 100% follow-up at 24+/-14 months (range, 0 to 54 months) was achieved. PATIENTS: As 3 of 92 patients died during hospital admission, the study follow-up population consisted of 89 of 92 patients (mean age, 67+/-10 years). The age of the SVGs was 10+/-4 years. RESULTS: We implanted 118 Palmaz-Schatz and 3 Gianturco-Roubin stents. Procedural success was achieved in 87 of 92 patients (94.5%; < 50% stenosis, and no death, Q-wave acute myocardial infarction, or coronary artery bypass graft [CABG]). Mean SVG stenosis diameter was reduced from 80+/-13% to -11+/-12% (p<0.001) and mean luminal diameter increased from 0.6+/-0.5 mm to 3.3+/-0.8 mm (p<0.001). At follow-up, angina pectoris had developed in 42 of 89 patients (47%), acute myocardial infarction in 12 of 89 patients (14%), reperformed CABG in 12 of 89 patients (14%), cardiac death in 10 of 89 patients (11%), and unrelated death in 6 of 89 patients (7%). Coronary angiography was performed in 37 of 89 patients (42%), with restenosis in 16 of 37 patients (43%) and disease progression at other sites in 11 of 37 patients (30%). Only 25 of 89 patients (28%) experienced event-free survival at follow-up. CONCLUSIONS: Despite high procedural success and excellent angiographic results with oversized balloon catheters, the long-term clinical outcome of SVG stent implantation is suboptimal.

Immediate and long-term results comparing coronary versus biliary tubular-slotted stents to treat old obstructed saphenous vein grafts.

Stenting of old obstructed saphenous vein grafts improves immediate angiographic results and long-term clinical outcome compared to standard balloon angioplasty. Comparison of results and long-term clinical outcome between different types of stents in the treatment of vein graft disease is scarce. The authors studied two matched groups of 33 patients each, receiving either coronary or biliary tubular-slotted stents in old vein graft lesions to compare immediate results and long-term clinical outcome. Patients in the two groups were matched for age and left ventricular function. Baseline angiographic characteristics, the minimal luminal diameter (MLD) (0.68 +/- 0.56 mm vs 0.61 +/- 0.51 mm, p = 0.9), and diameter stenosis (DS) (81 +/- 14% vs 82 +/- 15%) were similar between the groups. After stenting, the MLD (3.15 +/- 0.65 mm vs 3.37 +/- 0.63 mm, p = 0.9) and residual stenosis (-7 +/- 19% vs -11 +/- 21%) were also similar. The in-hospital major complications (myocardial infarction and death) (one vs eight, p = 0.01) and the combination of major and minor (bleeding and vascular) complications (eight vs 17, p = 0.02) were higher in the biliary stent group. At long-term follow-up, both groups of patients had high but comparable rates of major cardiovascular events (39% vs 45%, p = 0.62). Kaplan-Meier event-free survival analysis did not show any statistically significant difference in event-free survival (log-rank statistic 0.98). The authors conclude that patients receiving biliary stents had higher rates of immediate minor and major complications, but at long-term follow up, major cardiovascular event rates were comparable between the two groups of patients.

Results of saphenous vein graft stent implantation: single center results from use of oversized balloon catheters.

The results and complications of a single-center experience of stent implantation in old saphenous vein grafts (SVGs) need to be defined. The authors studied their initial consecutive 92 patients (125 stents, 1.4 stents/per patient) with a mean age of 67+/-9 years. The patients' mean saphenous vein graft (SVG) age was 10+/-4 years, and the mean left ventricular ejection fraction was 46%+/-15. Patient population included unstable angina (65%), stable angina (10%), myocardial infarction (21%), and silent ischemia (4%). The authors implanted 122 Palmaz-Schatz/biliary and three Gianturco-Roubin stents. They aimed at a balloon-artery ratio of 1.1/1.0. Procedural success, defined as stent deployment with <50% stenosis without death/Q-wave myocardial infarction/coronary artery bypass grafting (MI/CABG) was 95%. The mean luminal diameter (MLD) increased from 0.6+/-0.5 to 3.3+/-0.8 mm (p<0.001) and mean SVG stenosis diameter was decreased from 80%+/-14 to -10%+/-11 (p<0.001). Angiographic SVG lesions exhibited thrombus (17%), ulceration (38%), and plaque rupture (28%). Sixty-two patients were treated with warfarin and aspirin and 30 with ticlid and aspirin. Complications included death in three patients (3.3%) who sustained subacute stent thrombosis, and two of three had Q-wave MI. Distal embolization occurred in seven patients (8%); six of seven sustained a non Q-wave acute myocardial infarction (AMI); and one of seven a Q-wave MI. Eight (9%) patients had major groin hematoma, two had pseudoaneurysm (2.2%), one had arteriovenous (A-V) fistula (1.1%), two had vascular surgery (2.2%), nine had blood transfusion (9.8%), and three had stent migration (3.3%). Single-center experience with stents in SVGs indicates a highly successful procedural and angiographic immediate result. However, it was complicated by significant risk of non Q-wave MI due to distal coronary embolization which may affect prognosis.

Dobutamine stress echocardiography for assessing coronary artery disease after transplantation in children.

OBJECTIVES: The purpose of this study was to determine the feasibility, safety and diagnostic accuracy of dobutamine stress echocardiography (DSE) for evaluating posttransplant coronary artery disease (TxCAD) in children, and to determine the frequency of selected cardiac events after normal or abnormal DSE. BACKGROUND: Posttransplant coronary artery disease is the most common cause of graft loss (late death or retransplantation) after cardiac transplantation (CTx) in children. Coronary angiography, routinely performed to screen for TxCAD, is an invasive procedure with limited sensitivity. The efficacy of DSE for detecting atherosclerotic coronary artery disease is established, but is unknown in children after CTx. METHODS: Of the 78 children (median age 5.7 years, range 3 to 18) entered into the study, 72 (92%) underwent diagnostic DSE by means of a standard protocol, 4.6 +/- 1.9 years after CTx. The results of coronary angiography performed in 70 patients were compared with DSE findings. After DSE, subjects were monitored for TxCAD-related cardiac events, including death, retransplantation and new angiographic diagnosis of TxCAD. RESULTS: No major complications occurred. Minor complications, most often hypertension, occurred in 11% of the 72 subjects. The sensitivity and specificity of DSE were 72% and 80%, respectively, when compared with coronary angiography. At follow-up (21 +/- 8 months), TxCAD-related cardiac events occurred in 2 of 50 children (4%) with negative DSE, versus 6 of 22 children (27%) with positive DSE (p < 0.01). CONCLUSIONS: DSE is a feasible, safe and accurate screening method for TxCAD in children. Positive DSE identifies patients at increased risk of TxCAD-related cardiac events. Negative DSE predicts short-term freedom from such events.

Aortic balloon valvotomy/dilatation at crossroads.

A wide spectrum of aortic stenosis, results of aortic balloon valvotomy or dilatation will be variable. The author point out the unsatisfactory results with balloon valvotomy in young adults, which are contrary to those obtained in children. The place of this procedure in the palliative therapy of the aortic stenosis is discussed. However we need to develop more objective criteria and optimal timing to evaluate the results of this intervention.

Balloon valvotomy for pregnant patients with severe pliable mitral stenosis using the Inoue technique with total abdominal and pelvic shielding.

Balloon valvotomy by means of the Inoue technique was attempted in seven pregnant (5 to 9 months) patients with severe mitral stenosis; the mean age of the patients was 32 +/- 8 years, and all had a two-dimensional echocardiographic mitral valve score of < 8. Indications for Inoue balloon valvotomy included severe symptomatic mitral stenosis with a Doppler mitral valve area < or = 1 cm2 and heart failure refractory to medical therapy, or absolute contraindications for the use of beta-blockade; Inoue valvotomy was also indicated for patients who lived a long distance from the hospital. Inoue balloon valvotomy was performed with no angiography and total pelvic and abdominal shielding; the balloon catheter was introduced into the right atrium without the aid of fluoroscopy, which was used for the transseptal puncture. Stepwise two-dimensional echocardiographic Doppler mitral valve dilatation was done. After Inoue balloon valvotomy the mean Doppler mitral valve area increased from 0.8 +/- 0.1 to 2.0 +/- 0.3 cm2 (p < 0.01) and by two-dimensional echocardiography from 0.8 +/- 0.2 to 1.9 +/- 0.3 cm2 (p < 0.01), with no significant Doppler residual stenosis (defined as mitral valve area < or = 1.5 cm2). The mean total fluoroscopy time was 16 +/- 7 minutes. The degree of mitral regurgitation increased in two patients from grade 1+/4+ to grade 2+/4+ and from grade 0+/4+ to grade 2+/4+, respectively. There was no mortality or significant morbidity. Pregnancy was uneventful in all patients, and all were delivered of normal babies without complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous mitral balloon valvotomy in pregnancy using the Inoue balloon technique.

We describe a 40-year-old female who was 27 weeks pregnant and had severe rheumatic mitral valve stenosis. The patient presented with severe biventricular heart failure and fast atrial fibrillation. Soon after admission the patient sustained a cardiac arrest and was successfully resuscitated. Despite maximal medical therapy the patient was still in pulmonary edema. Beta blockers were contraindicated as the patient had bronchial asthma. Balloon mitral valvotomy using an Inoue 26 mm balloon catheter was done. The procedure was done with pelvic and abdominal shielding. To minimize radiation exposure no angiography was done and the procedure was done with echo-Doppler guided stepwise mitral valve dilatation. The mitral valve area after balloon valvotomy increased from 0.9 to 2 cm2. The total fluoroscopy time was 14 minutes. At 6-week follow-up the patient was virtually asymptomatic. Vaginal delivery was uneventful. Balloon mitral valvotomy using the Inoue technique in pregnancy with echo guided stepwise dilatation is accomplished with minimal radiation exposure, provided abdominal shielding is implemented throughout the procedure.

Double balloon aortic valvotomy for rheumatic aortic stenosis; in vivo studies.

The manner in which aortic valve area increases after in vitro double balloon aortic valvotomy for severe rheumatic aortic stenosis has not been defined. We selected ten intact aortic valves excised at cardiac surgery from patients (mean age 45 +/- 10 years) with severe rheumatic aortic stenosis, with a valve area less than or equal to 1 cm2. In vitro double balloon aortic valvotomy was attempted on each valve using two Meditech 15 mm diameter balloon catheters. The balloon catheters were simultaneously inflated to 4 atm pressure for 10 s. Before and after balloon valvotomy the valve area was calculated with a conical sizer, and radiological studies were also performed to study the effect of balloon valvotomy on calcified aortic commissures. The mean valve area increased from 0.7 +/- 0.2 (mean +/- SD) to 1.1 +/- 0.2 cm2 (P less than or equal to 0.001) after balloon valvotomy, with a mean total commissural splitting for each aortic valve of 9.3 +/- 6 mm. Overall, 63% of the aortic commissures were split, splitting occurring in 81% of non-calcified commissures and 43% of calcified commissures. There was no leaflet tear or calcium fracture either macroscopically or radiologically. Commissural splitting of rheumatic aortic stenosis is the manner in which valve area is increased after double balloon aortic valvotomy. The inflated balloon catheters split not only non-calcified, but also calcified arotic commissures. The adequate commissural splitting achieved and consequent 57% increase in valve area indicate that the double balloon aortic valvotomy technique may become a palliative therapeutic procedure for patients with severe rheumatic aortic stenosis.

Mechanism of mitral valve area increase by in vitro single and double balloon mitral valvotomy.

The mechanism of mitral valve area increase by double balloon mitral valvotomy in vitro has not been defined, nor have the mitral valve area results achieved by single versus double balloon mitral valvotomy technique been compared. After a selection of 29 intact mitral valves excised at cardiac surgery from patients with a mitral valve area less than or equal to 1.5 cm2 was made, double balloon mitral valvotomy was attempted in 14 valves using two 20-mm diameter balloon catheters (group 1) and single balloon mitral valvotomy using a 20-mm balloon was undertaken in 15 valves (group 2). In group 1 the mitral valve area increased from 0.9 +/- 0.03 to 1.9 +/- 0.05 cm2 (mean +/- standard error of the mean) (p less than 0.001), with a mean anterior commissural split of 5.3 +/- 0.2 mm and a posterior split of 4.1 +/- 0.2 mm. Following single balloon valvotomy (group 2), the mean mitral valve area increased from 0.8 +/- 0.03 to 1.2 +/- 0.03 cm2 (p less than 0.001), with the mean anterior commissural split being 2.6 +/- 0.2 mm and the posterior 2.1 +/- 0.2 mm. Ten mitral valves from group 2 underwent a second dilatation using the double balloon technique and the mitral valve area increased further from 1.2 +/- 0.06 to 1.9 +/- 0.06 cm2 (p less than 0.001). Overall, commissural splitting occurred preferentially in calcified commissures (81%), as opposed to only 56% of noncalcified commissures. Commissural splitting is the manner in which mitral valve area increases after double balloon mitral valvotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Brucella infective endocarditis. Successful combined medical and surgical therapy.

Five cases of Brucella infective endocarditis are described involving a native aortic valve, two native mitral valves, a mitral valve bioprosthesis, and a ventricular septal defect patch. The diagnosis of Brucella infective endocarditis was established from the clinical features, with a high Brucella serologic titer in each case. Blood and tissue cultures were positive in four of five patients. Two-dimensional echocardiograms demonstrated moderately large vegetations on the three affected native valves and the patch and also revealed the development of vegetation on the mitral bioprosthesis as the disease progressed. All the patients were successfully treated by combined surgical and medical therapy, the latter consisting of co-trimoxazole, tetracycline, and streptomycin/gentamicin for 6 weeks; the affected valves and the ventricular septal defect patch were all replaced. There were no operative deaths and there has been no recurrence of infection to date. One patient died suddenly of an unknown cause 1 year after the operation.

The value of cross-sectional echocardiography in detecting perioperative myocardial infarction following coronary artery bypass graft surgery.

Detection of perioperative myocardial infarction following coronary artery bypass graft surgery may be difficult. To assess the value of cross-sectional echocardiography in detecting perioperative infarction, 45 patients were studied by this technique to assess left ventricular regional wall motion before and eight to ten days after cardiac surgery. Deterioration in septal, antero-lateral, apical, inferior and posterior segments was correlated with Q-wave change in the ECG and with CK-MB taken at pre, 4, 7, 21, 48 and 72 hours post surgery. Echocardiographic regional wall motion was assessed semiquantitatively by a point score system (3 = normal, 2 = hypokinetic, 1 = akinetic, 0 = dyskinetic). Sixteen patients showed deterioration in regional wall motion greater than or equal to 1 point. Eleven of these patients had new hypokinetic abnormalities of 1 point in the previously normal septal segment, but no ECG infarction. Three of the 11 had raised CK-MB and only one fulfilled the CK-MB criteria for perioperative infarction. Four other patients showed new akinetic segments (deterioration of two points). All four had CK-MB criteria for perioperative infarction and three had new ECG Q-wave. Three other patients showed ECG infarction without echo or CK-MB changes. Thus the development of a new akinetic segment on cross-sectional echocardiographic analysis of regional wall motion is a good marker of perioperative myocardial infarction. However, the great majority of new septal hypokinetic segments do not result from this operative complication.

Antiplatelet drugs and the incidence of thromboembolic complications of the St. Jude Medical aortic prosthesis in patients with rheumatic heart disease.

The incidence of thromboembolic complications after St Jude Medical aortic valve replacement was evaluated in patients who received antiplatelet drugs alone (aspirin and dipyridamole). This report includes 107 consecutive patients undergoing aortic valve replacement with the St. Jude Medical prosthesis from February, 1980, until December, 1983. There were three perioperative deaths (2.8%). Thirty-seven of these patients received life-time warfarin anticoagulation and therefore were excluded from further analysis. The remaining 67 patients receiving antiplatelet drugs were followed up for 22 +/- 8 months (range 5 to 54 months) with a total observation period of 123 patient-years. Group 1 consisted of 52 patients having single St. Jude Medical aortic valve replacement (mean age 27 +/- 10 years). Group 2 included 15 patients having St. Jude Medical aortic valve replacement with additional mitral valve replacement (mean age 27 +/- 11 years). There were no postoperative embolic events in Group 1, but two St. Jude Medical aortic prostheses became thrombotic (2.1 per 100 patient-years) 19 and 32 months after the operation. Emergency aortic valve replacement was done in one of these patients and aortic thrombectomy in the other. Both patients are alive and doing well. In Group 2, three patients (10 per 100 patients-years) had thrombosis of the St. Jude Medical aortic valve 10, 12, and 30 months after the operation, and two of them required emergency aortic value replacement. One of these patients also had a massive left coronary embolus and could not be weaned from cardiopulmonary bypass. The third patient, who was asymptomatic, was prescribed warfarin anticoagulation and has been well. None of the seven patients in this group with St. Jude Medical aortic and mitral prostheses has had a thromboembolic event. These results indicate that antiplatelet drugs alone are associated with a very low risk of embolism but are insufficient to prevent thrombosis of St. Jude Medical aortic valves, even when the patients have sinus rhythm.