Predictors and patterns of chronic pain three months after cardiac surgery in Taiwan.

OBJECTIVES: Clinicians and researchers have a very limited understanding of how acute pain after cardiac surgery may develop into chronic pain. The aims of this study were to describe the pattern of pain during the first 3 months after cardiac surgery and to examine the predictors of surgery-related chronic pain. DESIGN: A prospective panel study was conducted to monitor changes in worst and average pain intensity before and during the first 3 months following cardiac surgery in a sample of Taiwanese patients. Fifty-three patients who underwent a midsternotomy rated pain intensity before surgery and at postoperative days 7, 10, 30, and 90. The participants also rated beliefs about opioid use, and their medical records were reviewed to document opioid use during the first week after surgery. RESULTS: The patients who reported chronic pain 90 days following surgery showed an unusual pattern of an increase in pain from 10 to 30 days after surgery. Higher worst pain intensity ratings at 30 days following surgery and more negative beliefs in opioid use were both associated with a greater likelihood of reporting chronic pain at 3 months. CONCLUSION: Patients reporting a pattern of increasing pain starting about 10 days after surgery and holding negative beliefs about opioid use are at risk of developing chronic pain and may require more careful monitoring and pain treatment. The possible benefits of interventions that minimize pain during the weeks after surgery and that alter negative beliefs about opioid use should be examined in future research.

Downregulated cardiac annexin VI mRNA and protein levels in chronically fibrillating human atria.

OBJECTIVES: We compared the expression and distribution of atrial annexin VI between patients with atrial fibrillation (AF) or sinus rhythm (SR). METHODS: Atrial appendages were obtained during cardiac surgery from 20 patients with chronic AF and 34 matched controls in SR. The expression and distribution of annexin VI were analyzed using semiquantitative RT-PCR, Western blotting and immunoconfocal microscopy. RESULTS: In the AF group, compared to SR, the mRNA was reduced to <35% and the protein to <50% in amount (for each atrium, all p < 0.01). Immunoconfocal microscopy confirmed the downregulation of annexin VI protein in AF and demonstrated the colocalization of annexin VI with both Na(+)/Ca(2+) exchangers and L-type Ca(2+) channels in the sarcolemma, but not with ryanodine receptors in the sarcoplasmic reticulum. CONCLUSIONS: Atrial annexin VI, spatially colocalized with both Na(+)/Ca(2+) exchangers and L-type Ca(2+) channels in the myocyte membrane, is downregulated during chronic AF.

B-vitamins, homocysteine and gene polymorphism in adults with fasting or post-methionine loading hyperhomocysteinemia.

BACKGROUND: Although fasting and post-methionine loading (PML) homocysteine concentrations are not necessarily related, a high percentage of hyperhomocysteinemia cases would be missed if methionine loading was not performed. AIM OF THE STUDY: The influences of B-vitamins and genetic polymorphism (methylenetetrahydrofolate reductase 677C --> T, MTHFR 677C --> T) on fasting and PML homocysteine concentrations and the relationship between fasting and PML homocysteine were studied. METHODS: This study was a cross-sectional study. Healthy subjects were divided into either fasting hyper-homocysteinemia (>or=12.2 micromol/l) (fasting hyper-hcy, n = 51), PML hyper-homocysteinemia (fasting homocysteine <12.2 micromol/l but PML homocysteine >or=25.6 micromol/l) (PML hyper-hcy, n = 29), or normo-homocysteinemia (fasting homocysteine <12.2 micromol/l and PML homocysteine <25.6 micromol/l) (normo-hcy, n = 118) group based on elevated fasting and PML homocysteine levels of the 75th percentile of the population. The concentrations of plasma fasting and PML homocysteine, serum folate, vitamin B-12, plasma pyridoxal 5'- phosphate (PLP) were measured. The genetic polymorphisms were determined. RESULTS: Fasting homocysteine, but not PML homocysteine and MTHFR 677C --> T genotype, was significantly and inversely affected by serum folate concentration after adjusting for potential confounders (beta = -0.062, P < 0.01). Fasting and PML homocysteine were highly associated in the fasting hyper-hcy and pooled groups (P < 0.01) but not in the PML hyper-hcy and normo-hcy groups. PML homocysteine did not interact with either serum folate (P = 0.302), vitamin B-12 (P = 0.465), plasma PLP (P = 0.996) or MTHFR 677C --> T genotype (P = 0.136) to affect fasting homocysteine concentration. CONCLUSIONS: Approximately one-third (36.3%) of hyperhomocysteinemia cases would be missed if methionine loading were not performed. Even though subjects may have a normal fasting homocysteine concentration, they need further screening for their PML homocysteine.

Plasma pyridoxal 5'-phosphate and high-sensitivity C-reactive protein are independently associated with an increased risk of coronary artery disease.

OBJECTIVE: Whether vitamin B6 exerts an independent or a synergic effect in combination with inflammation for the risk of coronary artery disease (CAD) is unclear. The purpose of this study was to investigate whether plasma pyridoxal 5'-phosphate (PLP) is dependent on or independent of the inflammation marker C-reactive protein (CRP) to associate with the risk of CAD. METHODS: This was a hospital-based case-control. Patients were identified with cardiac catheterization as having at least 70% stenosis of one major coronary artery were assigned to the case group (n = 184). The control group (n = 516) was comprised of healthy individuals with normal blood biochemical values. All subjects' height, weight, blood pressure, plasma PLP, homocysteine, high-sensitivity CRP (hs-CRP), and lipid profiles were measured. RESULTS: Plasma PLP concentration was only negatively associated with hs-CRP level in the control group (beta = -0.001, P = 0.03) but not in the CAD or pooled groups. The magnitude of the risk of CAD for low plasma PLP (odds ratio [OR] 2.39) and high hs-CRP (OR 3.37) was very similar. Low plasma PLP concentration combined with low hs-CRP level (OR 2.34) and high plasma PLP concentration combined with high hs-CRP level (OR 3.61) were independently associated with risk for CAD. However, the combined presence of low PLP and higher hs-CRP levels enhanced the risk of CAD and the magnitude was substantially greater (OR 4.35). CONCLUSION: Plasma PLP and hs-CRP are independently associated with an increased risk of CAD, the combined presence of low PLP and high hs-CRP enhanced the risk of CAD, and the magnitude was almost double.

Successful use of extracorporeal membrane oxygenation and drotrecogin alpha in patients with acute life-threatening myocarditis.

Acute fulminant myocarditis may present with cardiogenic shock refractory to inotropics and intra-aortic balloon pumping (IABP). Benefit of extracorporeal membrane oxygenation (ECMO) support has been established. The effectiveness of combination with ECMO or IABP and activated protein C (drotrecogin alpha; Xigris) in treatment has yet to be defined. Four patients presented with congestive heart failure 3-4 days after flu-like symptoms. Chest roentgenograms showed cardiomegaly and bilateral pulmonary infiltrates. Two-dimensional echocardiograms demonstrated severe myocardial dysfunction with left ventricular ejection fraction (LVEF), measured between 18.4% to 27% (mean, 19.5%). Three patients having been treated with the combination of ECMO or IABP and activated protein C were weaned. Follow-up LVEF measured were 39.9%, 43%, 53%, and 55%, respectively. However, 1 patient died a month later because of systemic lupus erythematosus and repeated infection. There were no neurologic sequelae in the 3 survivors. Serological test and myocardial biopsy for Parvovirus B19 was positive in 3 of 4 patients. Use of circulatory support and activated protein C is an effective alternative for acute life-threatening myocarditis.

Effects of thermal preconditioning on the ischemia-reperfusion-induced acute lung injury in minipigs.

Lung ischemia-reperfusion (I/R) injury plays an important role in many clinical issues. A series of mechanisms after I/R has been uncovered after numerous related studies. Organ preconditioning (PC) is a process whereby a brief antecedent event, such as transient ischemia, oxidative stress, temperature change, or drug administration, bestows on an organ an early or delayed tolerance to further insults by the same or different stressors. In this study, we want to uncover the optimal thermal PC patterns that cause maximal early or delayed protective effect on the subsequent pulmonary I/R with the use of miniature pig model. Twenty-eight 15- to 20-kg weight Lanyu miniature pigs are used and divided into four groups (seven sham operation control [NC], seven PC only [PC], seven I/R [I/R], and seven PC followed by I/R [PC + I/R]). The PC was performed with the animals being anesthetized and, using an alternative hyperthermic (40 degrees C) and normothermic moist air to ventilate their lungs for 15 min, respectively, for 2 cycles, followed by I/R, which consists of 90 min of blocking the perfusion and ventilation of the left lung followed by 240 min of reperfusion. Control animals had a thoracotomy with hilar dissection only. Indicators of lung injury included hemodynamic parameters, blood gas analysis, histopathological (lung pathology, wet/dry weight ratio, myeloperoxidase assay), and molecular biological profiles (interleukin-1beta [IL-1beta], IL-6, tumor necrosis factor-alpha by enzyme-linked immunosorbent assay analysis). Lung tissue heat shock protein 70 (HSP-70) expression was also detected by Western blotting. This model of lung I/R induced significant lung injury with pulmonary hypertension, increased pulmonary vascular resistance, and pulmonary venous hypoxemia at the ischemia side, increased pulmonary tissue injury score and neutrophil infiltration, increased wet/dry ratio, myeloperoxidase assay, tumor necrosis factor-alpha, IL-1beta, and IL-6 assay. This type of thermal PC would not injure the lung parenchyma or tracheal epithelium. Moreover, it could attenuate the I/R-related lung injury, with some of these parameters improved significantly. Increased expression of HSP-70 was also found in the group of PC plus I/R than the I/R only. Less prominent and transient increase in expression of HSP-70 was found in the PC group. We concluded that the intratracheal thermal PC can effectively attenuate I/R-induced lung injury through various mechanisms, including the decrease of various proinflammatory cytokines. The mechanism of its protective effect might be related to the increased expression of HSP-70.

Comparison of the postoperative blood flow waveforms of the bypassing grafts in patients following minimally invasive direct coronary artery bypass.

PURPOSE: To use Doppler ultrasound velocimetry to detect and compare the postoperative flow characteristics of the bypassing grafts in patients following minimally invasive direct coronary artery bypass surgery (MIDCAB). MATERIALS AND METHODS: From January 1997 to June 1999, 34 patients underwent MIDCAB with the left internal thoracic artery (LITA) to the left anterior descending coronary artery (LAD) [n = 23], with the right gastroepiploic artery (RGEA) to the right posterior descending artery (RPD) [n = 3], or with the LITA with a saphenous vein graft extension to the LAD (n = 6), the diagonal coronary artery (n = 1), or the right acute coronary artery (n = 1). There were two patients with LITA to the LAD and RGEA to the RPD. Patients underwent MIDCAB due to coronary artery stenosis (100% occlusion, n = 10; 90 to 99% stenosis, n = 18; < 90% stenosis, n = 5) or unsuccessful percutaneous transcoronary angioplasty with dissection (n = 1). All patients underwent flow velocity measurement by Doppler ultrasound velocimetry in the immediate postoperative period, and at 6-month and 12-month intervals; graft flows were quantified based on Doppler velocimetric data. RESULTS: The results showed that in a patient with a totally occluded LAD or RPD, typical biphasic velocity waveforms were consistently observed. However, a delayed diastolic wave was noted in RGEA grafts. In patients with less-occluded stenotic lesions or with strong back flows, the flow velocity patterns showed biphasic waveforms but systolic reversal was observed in the area closest to the anastomotic site. CONCLUSION: The presence of an LAD or RPD stenosis proximal to the anastomotic site significantly affects the LITA or RGEA graft flow volume. The biphasic flow pattern proves that an LITA or RGEA graft transports the blood primarily to coronary arteries during the diastolic phase.

Change of serum growth factors in infants with isolated ventricular defect undergoing surgical repair.

BACKGROUND: Despite increasing clinical use and recent evidence that insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3), and human growth hormone (hGH) target the heart, the clinical manifestations following the change in the serum growth factors in infants with isolated ventricular septal defect (VSD) undergoing surgical repair have not been clearly defined. METHODS: Twenty normal infants (group I) and 44 consecutive infants with echocardiography established isolated VSD (aged from 3 months to 1 year; body weight from 6.0 +/- 1.8 kg to 8.2 +/- 1.6 kg) were investigated. Among 44 infants with VSD, 20 with shunt fraction, Qp/Qs < or = 1.5 were free of symptoms of congestive heart failure (group II); 24 with shunt fraction, Qp/Qs > or = 2.0 were in congestive heart failure (group IIIa); and 20 of these 24 infants had undergone VSD repair 6 months before their second study (group IIIb). Serum IGF-1, IGFBP-3, and hGH factors were determined by enzyme-linked immunosorbent assay using a monoclonal antibody. RESULTS: The serum levels of IGF-1, IGFBP-3, and hGH factors were 111.9 +/- 2.3 ng/mL, 22.0 +/- 2.3 ng/mL, and 3.6 +/- 0.7 microIU/mL for group I; 63.8 +/- 8.2 ng/mL, 17.1 +/- 1.6 ng/mL, and 4.1 +/- 1.2 microIU/mL for group II; 24.0 +/- 2.6 ng/mL, 9.4 +/- 0.7 ng/mL, and 14.7 +/- 3.5 microIU/mL for group IIIa; 79.4 +/- 12 ng/mL, 20.3 +/- 1.3 ng/mL, and 4.3 +/- 0.7 microIU/mL for group IIIb. In comparison to group I, the decrease in serum levels of IGF-1 and IGFBP-3 in groups II and IIIa were statistically significant (in group II 43% and 32%, p < 0.05; in group IIIa 79% and 37%, p < 0.01). Also the increase in serum level of hGH concentration in group IIIa was significant (increased threefold, p < 0.01). Interestingly, the change in serum levels of IGF-1, IGFBP-3 (decrease), and hGH (increase), returned to the normal range of serum levels after VSD repair in group IIIb. All congestive heart failure symptoms subsided in group IIIb during follow-up. CONCLUSIONS: Improvement in serum levels of IGF-1, IGFBP-3, and hGH were identified in infants with VSD after surgical repair.

Cardiac surgery in patients aged at least 80 years.

Cardiac surgery in patients aged 80 years and over has become more acceptable with improvements in health care services and the steady increase in the number of octogenarians in the population. These demographic changes are reflected in an increasing number of octogenarians with advanced symptomatic disease undergoing complex cardiac intervention. We reviewed data from 62 articles on cardiac surgery in octogenarians. The medical and ethical issues involved in making the decision are complex. Long-term results of cardiac surgery in octogenarians show that these patients can withstand heart surgery with improved functional benefit and quality of life. Surgery is beneficial especially for patients undergoing coronary artery revascularization or isolated aortic valve surgery. The operative course in octogenarians is more complicated, which is reflected in longer postoperative hospitalization. In refutation of the assumption that mortality in octogenarians is related to multisystem failure, most deaths are cardiac in nature. Highly selective criteria (identifying risks and benefits individually) should be applied to octogenarians undergoing cardiac surgery to achieve a satisfactory result.

Comparison of histidine-tryptophan-ketoglutarate and Euro-Collins solutions for lung preservation using the minipig in situ warm ischemia model.

BACKGROUND AND PURPOSE: Reperfusion injury remains a common problem in lung transplantation. This study compared the effect of lung preservation with histidine-tryptophan-ketoglutarate (HTK), a relatively low potassium solution, and Euro-Collins (EC) solution by using a minipig in situ model of warm ischemia. METHODS: The left lungs of 5 minipigs were selectively flushed with EC solution. HTK was used for flush perfusion in 6 other minipigs. After 60 minutes of warm ischemia, the left lungs were reperfused. Hemodynamics, aerodynamics, and arterial blood gas were measured after the blood flow and ventilation of the contralateral lungs were temporally blocked. Bronchoalveolar lavage fluid (BALF) analysis, lung wet-to-dry weight ratio (W/D ratio) and histological analysis were done before perfusion (right lung) and 2 hours after reperfusion (left lung). RESULTS: This in situ model of warm ischemia induced significantly increased pulmonary arterial pressure, pulmonary vascular resistance, BALF albumin contents and neutrophil counts, histological injury score, lung W/D ratio and tissue myeloperoxidase assay. The HTK perfusion group had a significantly lower degree of lung injury than the EC perfusion group. CONCLUSIONS: Lung preservation with HTK solution resulted in better lung function after reperfusion than preservation by EC solution in this minipig model.

Effect of Surgecel coverage with topical electrocauterization for preventing and sealing pulmonary air leakage.

Pleural tears usually occur after pneumolysis for dense adhesion or after cone biopsy of lung parenchyma. Repair of the tears is sometimes very difficult. Herein we compared different methods on a pig lung air leak model. Twenty pigs with pleural tears by surgical manipulation through sternotomy were not treated (n = 5) or treated by simple electroablation (n = 5), pleural coverage (n = 5), or Surgecel coverage with surface electroablation (n = 5). We evaluated their immediate and delayed treatment effect by measuring the critical leak pressure, degree of air leakage, and air leakage period and histological examination. It was found that Surgecel coverage with surface electrocauterization had similar early and delayed effects in sealing air leakage to pleural coverage and was much better than the other two groups (P < 0.05). We conclude that coverage with Surgicel with local electroablation can significantly decrease immediate and late air leakage from pleural tears.

Remodeled left ventricular myocardium remote to infarction sites is the arrhythmogenic substrate for sudden cardiac death.

Ventricular tachyarrhythmias are life threatening cardiac arrhythmias and are the most common causes of sudden cardiac death. Greater post-infarction left ventricular remodeling has been shown to have a greater preponderance of ventricular arrhythmias. The hypothesis herein is that adverse structural and electrophysiological remodeling at non-infarcted regions after myocardial infarction constitutes the arrhythmogenic substrate responsible for clinically occurring ventricular arrhythmias leading to sudden cardiac death. Post-infarction patients with more severe left ventricular remodeling (regional hypertrophy) at sites remote to infarction scar might have the highest risk for sudden cardiac death due to lethal ventricular arrhythmias. In the hypertrophic non-infarcted zone, larger action potential duration and repolarization heterogeneity is not in self arrhythmogenic, but can predispose towards arrhythmia development under certain condition, such as transient myocardial ischemia. We should draw more attention to apparently "normal" non-infarction region for further understanding the mechanism of sudden cardiac death.

Serum folate is a reliable indicator of hyperhomocysteinemia and borderline hyperhomocysteinemia in young adults.

Serum folate has been shown to correlate well with fasting plasma homocysteine; however, erythrocyte folate concentration is a better index of tissue folate stores and probably could be a more reliable indicator for reflecting long-term supply of the vitamin and homocysteine status. The present study was undertaken to test the hypothesis that serum folate and erythrocyte folate levels had a different degree of correlation to fasting plasma homocysteine in young Taiwanese adults. This study had a cross-sectional design. Healthy young adults were divided into either a hyperhomocysteinemia (HHcy; > or =14.9 micromol/L; n = 13), borderline HHcy (BHcy; fasting homocysteine, 14.9-10.2 micromol/L; n = 52), or normohomocysteinemia (fasting homocysteine, <10.2 micromol/L; n = 65) groups based on fasting homocysteine levels. The concentrations of plasma fasting homocysteine, serum folate, erythrocyte folate, vitamin B(12), and plasma pyridoxal 5'-phosphate were measured. Fasting homocysteine was only significantly and inversely affected by serum folate (beta = -0.21, P < .05) concentration after adjusting for potential confounders. Only serum folate concentration remained to decrease the risk of fasting HHcy (odds ratio, 0.73; confidence interval, 0.56-0.95) after the other B vitamins were additionally adjusted. Serum folate also had the highest area under the receiver operating characteristic (AUC) curve to predict the risk of HHcy (AUC, 0.81) and BHcy (AUC, 0.77). Serum folate is a reliable indicator of fasting hyperhyperhomocysteinemia and BHcy in young adults.

High plasma homocysteine is associated with the risk of coronary artery disease independent of methylenetetrahydrofolate reductase 677C-->T genotypes.

Hyperhomocysteinemia is an independent risk factor for coronary artery disease (CAD). The aim of this study was to investigate the relations between the methylenetetrafolate reductase (MTHFR) 677C-->T genotypes, B-vitamins (folate, vitamin B-12 and B-6), homocysteine and the risk of CAD. In this case-control study, patients who were identified by cardiac catheterization as having at least 50% stenosis of one major coronary artery were assigned to the case group (n=121). Healthy individuals with normal blood biochemical values were assigned to the control group (n=155). Healthy subjects were matched to case subjects for age. The concentrations of plasma homocysteine, serum folate, vitamin B-12, plasma pyridoxal 5'- phosphate (PLP) and MTHFR 677C-->T gene polymorphism were obtained. The T-allele carriers had significantly higher plasma homocysteine concentration compared to subjects with the 677CC genotype. The MTHFR 677C-->T genotypes were associated with plasma homocysteine after adjusting for various potential risk factors in the case and pooled groups. The MTHFR genotypes were found to have no associations with the risk of CAD. However, plasma homocysteine (>or= 12.5 micromol/L) (OR, 3.49; 95% CI, 1.23-9.88) had a significant association with increased risk of CAD even after additionally adjusted folate status. High plasma homocysteine concentration had a direct effect on the risk of CAD independent of MTHFR 677C-->T genotypes.

Minimally invasive cardiac surgery for resection of right atrial hepatic tumor in an octogenarian.

Removal of right atrial hepatic tumor with caval involvement requires control of bleeding, avoidance of tumor embolization, and adequate resection. We reported an octogenarian having hepatocellular carcinoma with caval and right atrial involvements who underwent successful resection using cardiopulmonary bypass and intraoperative transesophageal echocardiography.

Who makes the decision? Patient's autonomy vs paternalism in a Confucian society.

Through the ages health professionals have depended on patients' co-operation and obedience as essential aspects of cure. The Code of Ethics of the American Medical Association in 1848, section 6, stated that "the obedience of a patient to the prescription of his physician should be prompt and implicit..." But A Patient's Bill of Rights published by the American Hospital Association in 1973 said that "the patient has the right to refuse treatment to the extent permitted by law..." At a quick glance, these two statements seem to put these two parties in conflict. The situation could even be more complicated when cultural elements are added to the consideration of who makes the final decision. A survey taken in the summer of 2002 in Taiwan showed that in a Confucian society, the family element often determines the course of decision and the patient's autonomy is overlooked. The head of the family, not the patient himself or herself, usually makes the decision, especially when the medical decision has something to do with a life or death situation.

Developing an optimal emergence profile of the definitive restoration with a modified impression cap technique for ITI solid abutment.

There appears to be no convenient method for fabricating an optimal emergence profile for the definitive restoration of an ITI solid abutment when the implant is installed subgingivally. This article describes an efficient technique to solve this problem and reviews its advantages and disadvantages.

Does the suggested lightwand bent length fit every patient? The relation between bent length and patient's thyroid prominence-to-mandibular angle distance.

BACKGROUND: To date, no study has explored the effect of bent length on lightwand intubation. For successful intubation in daily practice, the authors found that bent length should be approximated to the patient's thyroid prominence-to-mandibular angle distance (TMD), but some patients have a TMD much shorter than the suggested bent length range. The purposes of this study were to understand TMD distribution in adults and to test the influence of bent length on lightwand intubation. METHODS: The TMD, airway, and demographic data of 379 patients were collected. To test the bent length influence, patients were enrolled in group A (158 patients, TMD 5.5 cm) and were intubated randomly using the lower (6.5 cm) and upper (8.5 cm) limits of the suggested range. Success rate and lightwand search time were compared. RESULTS: In group A, the success rate was 98.8% with 6.5-cm bent length and 78.2% with 8.5-cm bent length (P < 0.05). Search times were 5.7 +/- 2.90 and 8.9 +/- 5.80 s with 6.5- and 8.5-cm bent length, respectively (P < 0.01). In group B, there was no statistical difference in success rate and search time between 6.5- and 8.5-cm bent length. CONCLUSION: The suggested range was suitable for patients in group B (TMD > 5.5 cm). However, in group A (

Prolactin secretion and intracellular Ca(2+) change in rat lactotroph subpopulations stimulated by thyrotropin-releasing hormone.

Thyrotropin-releasing hormone (TRH) may stimulate lactotrophs to increase intracellular Ca(2+) and to secrete prolactin (PRL). In this study, PRL contents in lactotrophs were determined by the sequential cell immunoblot assay (SCIBA) and their changes in intracellular Ca(2+) was analyzed by confocal microscopy. Significant correlations were found in the corresponding parameters between TRH treatments with a recovery interval of 2 h. Measuring the PRL contents after the first TRH treatment and then determining the intracellular Ca(2+) changes after the second TRH treatment revealed four lactotroph subpopulations. Type I cells (51%) showed significant responses of both PRL secretion and intracellular Ca(2+) concentration. Type II cells (22%) increased in PRL secretion, but without changes in intracellular Ca(2+). Type III cells (17%) have increased in intracellular Ca(2+), but without changes in PRL secretion. Type IV cells (10%) did not show changes in PRL secretion and intracellular Ca(2+).