EuroSCORE II and N-terminal pro-B-type natriuretic peptide for risk evaluation: an observational longitudinal study in patients undergoing coronary artery bypass graft surgery.

BACKGROUND: Postoperative heart failure remains the major cause of death after cardiac surgery. As N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a predictor for postoperative heart failure, the aim was to evaluate if preoperative NT-proBNP could provide additional prognostic information to the recently launched EuroSCORE II. METHODS: A total of 365 patients with acute coronary syndrome (ACS) undergoing isolated coronary artery bypass graft (CABG) surgery were studied prospectively. Preoperative NT-proBNP and EuroSCORE II were evaluated with regard to severe circulatory failure after operation according to prespecified criteria. To assess what clinical outcomes are indicated by NT-proBNP levels in different risk categories, the patients were stratified according to EuroSCORE II. Based on receiver operating characteristics analysis, these cohorts were assessed with regard to preoperative NT-proBNP below or above 1028 ng litre(-1). The follow-up time averaged 4.4 (0.7) yr. RESULTS: Preoperative NT-proBNP≥1028 ng litre(-1) [odds ratio (OR) 9.9, 95% confidence interval (CI) 1.01-98.9; P=0.049] and EuroSCORE II (OR 1.24, 95% CI 1.06-1.46; P=0.008) independently predicted severe circulatory failure after operation. In intermediate-risk patients (EuroSCORE II 2.0-10.0), NT-proBNP≥1028 ng litre(-1) was associated with a higher incidence of severe circulatory failure (6.6% vs 0%; P=0.007), renal failure (14.8% vs 5.4%; P=0.03), stroke (6.6% vs 0.7%; P=0.03), longer intensive care unit stay [37 (35) vs 27 (38) h; P=0.002], and worse long-term survival. CONCLUSIONS: Combining EuroSCORE II and preoperative NT-proBNP appears to improve risk prediction with regard to severe circulatory failure after isolated CABG for ACS. NT-proBNP may be particularly useful in patients at intermediate risk according to EuroSCORE II. CLINICAL TRIAL REGISTRATION: NCT00489827.

Mixed venous oxygen saturation predicts short- and long-term outcome after coronary artery bypass grafting surgery: a retrospective cohort analysis.

BACKGROUND: Complications of an inadequate haemodynamic state are a leading cause of morbidity and mortality after cardiac surgery. Unfortunately, commonly used methods to assess haemodynamic status are not well documented with respect to outcome. The aim of this study was to investigate Sv(O2) as a prognostic marker for short- and long-term outcome in a large unselected coronary artery bypass grafting (CABG) cohort and in subgroups with or without treatment for intraoperative heart failure. METHODS: Two thousand seven hundred and fifty-five consecutive CABG patients and subgroups comprising 344 patients with and 2411 patients without intraoperative heart failure, respectively, were investigated. Sv(O2) was routinely measured on admission to the intensive care unit (ICU). The mean (sd) follow-up was 10.2 (1.5) yr. RESULTS: The best cut-off for 30 day mortality related to heart failure based on receiver-operating characteristic analysis was Sv(O2) 60.1%. Patients with Sv(O2) <60% had higher 30 day mortality (5.4% vs 1.0%; P<0.0001) and lower 5 yr survival (81.4% vs 90.5%; P<0.0001). The incidences of perioperative myocardial infarction, renal failure, and stroke were also significantly higher, leading to a longer ICU stay. Similar prognostic information was obtained in the subgroups that were admitted to ICU with or without treatment for intraoperative heart failure. In patients admitted to ICU without treatment for intraoperative heart failure and Sv(O2) ≥60%, 30 day mortality was 0.5% and 5 yr survival 92.1%. CONCLUSIONS: Sv(O2) <60% on admission to ICU was related to worse short- and long-term outcome after CABG, regardless of whether the patients were admitted to ICU with or without treatment for intraoperative heart failure.

Role of alloantigens in natural killing. Allogeneic but not autologous tumor biopsy cells are sensitive for interferon-induced cytotoxicity of human blood lymphcoytes.

Blood lymphocytes of patients with solid tumors were assayed for cytotoxicity against autologous and allogeneic primary tumor cells. The lymphocytes killed autologous tumor cells in 7 of 25 cases (28%) and allogeneic tumor cells in 2 of 37 tests (5%). Lymphocytes from healthy donors were rarely cytotoxic for the biopsy cells, which indicates that these cells have low natural kill sensitivity. The autoreactivity that may reflect the immunological recognition of tumor cells was not altered by pretreatment of the effectors with interferon (IF). In contrast, killing of allogeneic tumor biopsy cells was induced by IF in approximately 50% of tests, with the lymphocytes of both the tumor patients and the healthy donors. The mechanism of the alloreactivity is most likely a consequence of IF-induced polyclonal activation of cytotoxic potential and the lymphocytes that are committed to recognize the alloantigens expressed on the particular target manifest the killing function. When the biopsy cells were explanted and kept in culture for 5-6 d, their susceptibility for the lymphocyte damage increased, and they were killed by the IF-treated cells also in autologous combinations. Whether this change in sensitivity is a result of qualitative or quantitative changes in antigen expression or of other changes in the properties of the cell membrane is unknown.

Lysis of tumor biopsy cells by autologous T lymphocytes activated in mixed cultures and propagated with T cell growth factor.

Blood lymphocytes from tumor patients were cocultivated with allogeneic lymphocytes (MLC) or autologous tumor cells (ATS), and their cytotoxicity was characterized. The main objective of the study was the lysis of autologous tumor biopsy cells by such effectors. Lymphocytes of patients activated in MLC lysed allogeneic third-party cells and in some cases also lysed autologous tumor cells. Allogeneic but not autologous PHA blasts were also damaged by these effectors. The cytotoxic potential of MLC-activated lymphocytes from healthy donors was similar; allogeneic tumors and phytohemagglutinin (PHA) blasts but not autologous PHA blasts were lysed. The cytotoxicity of lymphocytes activated in ATS were specific for the stimulator because they acted only on the autologous tumor cells. Allogeneic tumors and autologous and allogeneic PHA blasts were not lysed. The pattern of cytotoxicity with regard to this target panel was maintained when the MLC or ATS cultures were further propagated with TCGF. Results obtained in cold target competition assays suggested (a) activated lymphocyte lyse the third party tumor targets because of alloantigen recognition; (b) in MLC several different sets of alloreactive cytotoxic lymphocytes are present simultaneously; and (c) the alloreactive cells are different than those that act on the autologous tumor cells. Thus, the lysis of allogeneic tumor cells by lymphocytes of the patient is not due to recognition of cross-reacting tumor-related antigens, and the autotumor cytotoxicity of the patients' MLC-activated lymphocytes if performed by specifically reacting cells.

Mixed venous oxygen saturation is a prognostic marker after surgery for aortic stenosis.

BACKGROUND: Adequate monitoring of the hemodynamic state is essential after cardiac surgery and is vital for medical decision making, particularly concerning hemodynamic management. Unfortunately, commonly used methods to assess the hemodynamic state are not well documented with regard to outcome. Mixed venous oxygen saturation (SvO(2)) was therefore investigated after cardiac surgery. METHODS: Detailed data regarding mortality were available on all patients undergoing aortic valve replacement for isolated aortic stenosis during a 5-year period in the southeast region of Sweden (n=396). SvO(2) was routinely measured on admission to the intensive care unit (ICU) and registered in a database. A receiver operating characteristics (ROC) analysis of SvO(2) in relation to post-operative mortality related to cardiac failure and all-cause mortality within 30 days was performed. RESULTS: The area under the curve (AUC) was 0.97 (95% CI 0.96-1.00) for mortality related to cardiac failure (P=0.001) and 0.76 (95% CI 0.53-0.99) for all-cause mortality (P=0.011). The best cutoff for mortality related to cardiac failure was SvO(2) 53.7%, with a sensitivity of 1.00 and a specificity of 0.94. The negative predictive value was 100%. The best cutoff for all-cause mortality was SvO(2) 58.1%, with a sensitivity of 0.75 and a specificity of 0.84. The negative predictive value was 99.4%. Post-operative morbidity was also markedly increased in patients with a low SvO(2). CONCLUSION: SvO(2), on admission to the ICU after surgery for aortic stenosis, demonstrated excellent sensitivity and specificity for post-operative mortality related to cardiac failure and a fairly good AUC for all-cause mortality, with an excellent negative predictive value.

Myocardial metabolism before and after valve replacement for aortic stenosis.

AIM: Post ischemic disturbances of myocardial metabolism that may contribute to postoperative heart failure and are accessible to metabolic treatment have been identified early after coronary surgery. Knowledge derived from these studies may not be applicable to other patient groups. Therefore we studied myocardial energy metabolism in patients operated for isolated aortic stenosis. METHODS: Twenty patients undergoing isolated aortic valve replacement (AVR) because of aortic stenosis without significant regurgitation were studied before and immediately after surgery. Myocardial uptake of oxygen and energy substrates was assessed with coronary sinus catheter technique. RESULTS: Free fatty acids (FFA) were the main source of myocardial energy before and after AVR. A significant uptake of lactate was only recorded preoperatively. A significant uptake of glutamate of the same magnitude as previously described in coronary patients was found pre- and postoperatively. Postoperatively a relative decrease of myocardial oxygen extraction ratio (P<0.001) and oxygen consumption (P=0.14) by approximately 20% was observed. CONCLUSION: Preoperative and postoperative metabolic adaptation with substantial uptake of glutamate, previously claimed to be due to chronic or repetitive ischemia, was demonstrated. The results indicate that oxidative metabolism had not fully recovered when the procedure was completed. However, the potentially unfavorable postoperative metabolic state with predominant reliance on FFA as energy source was out-balanced by the unloading effect of AVR with a reduction in myocardial oxygen extraction.

Natural cytotoxicity of human blood lymphocytes and monocytes and their cytotoxic factors: effect of interferon on target cell susceptibility.

The effect of interferon (IFN) on target cell susceptibility to human natural killer (NK) cells and monocytes was analyzed in direct cell-mediated and their cytotoxic factor-mediated cytotoxicity assays. Treatment of K562 cells with IFN resulted in a decrease in their sensitivity to lysis by nonadherent lymphocytes and Percoll-purified large granular lymphocytes (LGL) when tested in a 4-hour 51Cr release assay. In contrast, the treatment did not affect the target susceptibility to monocytes purified by adherence to autologous serum-coated plastic surfaces. In the target-binding assay with LGL or monocytes the number of conjugates was not altered after IFN treatment of K562. Lymphocytes and monocytes were induced to release soluble cytotoxic factors, termed "natural killer cytotoxic factors (NKCF) and monocyte cytotoxic factors (MCF)," respectively, when co-cultured with K562. Both NKCF and MCF lysed K562 in a 48-hour microcytotoxicity assay or in an 18-hour 51Cr release assay in the presence of dactinomycin. IFN-treated K562 reduced or completely lost their ability to stimulate the release of NKCF, whereas they triggered MCF secretion as effectively as did the untreated K562. When lymphocytes or monocytes were pretreated with IFN, they released NKCF or MCF with augmented lytic activity. In contrast to the sensitivity to NK cell-mediated lysis, IFN pretreatment of K562 induced no change in their susceptibility to NKCF and MCF. When IFN was added to NKCF and MCF assays, the cytotoxicity was enhanced. The addition of IFN to K562 that had been pretreated with NKCF or MCF and washed resulted in no increase in lysis. The capacity of K562 to absorb the lytic activity of NKCF and MCF was not altered by IFN. These results indicate that IFN treatment of target cells can be used to distinguish the two distinct types of blood mononuclear cells with natural cytotoxicity, NK cells and monocytes, and that each effector cell type is stimulated to release cytotoxic factors by the different target determinant after the initial effector-target cell binding.

Human tumor-lymphocyte interaction in vitro. VI. Specificity of primary and secondary autologous lymphocyte-mediated cytotoxicity.

A T-cell-enriched lymphocyte subset of samples from 15 tumor patients was tested for primary cytotoxicity against autologous tumor cell preparations and against 1-3 different allogeneic tumor cell preparations from biopsy material. Allogeneic cytotoxicity occurred in only 1 of 10 patients with autologous reactivity. The lymphocytes of 14 patients were cultured with autologous cells from biopsy material for 6 days. These lymphocytes killed autologous targets, but only 1 patient's lymphocytes were cytotoxic against 1 of the 4 allogeneic tumors tested. Cocultivation with allogeneic cells from biopsy specimens generated cytotoxicity toward the sensitizing allogeneic cells in 3 of 9 test combinations. In 2 of 3 instances the effectors were also active against the autologous tumor cells. Cytotoxicity in primary and secondary tests occurred thus only rarely against allogeneic targets. This indicated either the presence of individual tumor-related antigens on the cells from biopsy material or reflected the histocompatibility restriction of T-cell-mediated cytotoxicity.

Selectively down-regulated expression of major histocompatibility complex class I alleles in human solid tumors.

We studied the expression of major histocompatibility complex (MHC) class I molecule in 52 ex-vivo tumor samples comprising 29 ovarian, 15 lung, 1 breast, and 4 colon carcinomas; 1 midgut carcinoid; and 2 malignant mesenchymal tumors obtained from surgical specimens or from malignant effusions. The allelic products were visualized in untreated and interferon gamma + tumor necrosis factor alpha treated aliquots of tumor cells and in the patient's blood lymphocytes by the one-dimensional isoelectric focusing method. Generally, the tumor cells contained lower amounts of MHC class I molecules compared to the lymphocytes. In vitro exposure to interferon gamma and tumor necrosis factor alpha elevated the level of MHC class I expression in 24 of 52 tumors and corrected the assembly defect seen in 2 cases. In 20 tumors one or several human leukocyte antigen alleles were undetectable even after cytokine treatment. Correlation was seen with the grade of differentiation; the proportion of tumors with selective losses in poorly, moderately, or well differentiated tumors were 16 of 30, 3 of 13, and 1 of 9, respectively. Selective losses occurred in ovarian carcinoma cells collected from malignant effusions (12 of 22, 54%) but not in 7 primary tumors. In primary lung carcinomas the frequency was 36% (5 of 14 cases). Thirty-nine patients were serologically typed; thus the MHC alleles on the tumor cells could be identified. In this panel of tumors 30 human leukocyte antigen alleles were represented. Among these the expression of 15 was found to be down-regulated in some but not all tumors of the same histology.

Membrane structures involved in auto-tumor recognition.

Tumor patients' blood lymphocytes have the capacity to recognize autologous tumor cells in vitro. A consequence of this recognition is the proliferation of small-size, high-density, resting T cells. Both helper (CD4+) and cytotoxic/suppressor (CD8+) T lymphocytes proliferate in the mixed lymphocyte-tumor cell cultures. In contrast to the autologous mixed lymphocyte cultures, both the auto-erythrocyte rosetting and non-rosetting (AE+ and AE-) T cells participate in the auto-tumor response. In contrast to stimulation by virus-infected or hapten-modified cells, DR antigen expression is not essential for stimulation by autologous tumor cells. In a proportion of cancer patients, blood lymphocytes have the capacity to lyse the patients' own tumor cells in vitro. There are two populations of lymphocytes with auto-tumor cytotoxic function. The first is characterized by low buoyant density and by non-adaptive cytotoxicity. In contrast to the recognition of hapten-modified or virus-infected target cells by the CTL, recognition of autologous tumor cells by the cytotoxic LD cells occurs even when the MHC class I antigens are blocked by mAb. The CD3 complex is also not involved in LD-mediated lysis. The other population with auto-tumor cytotoxic function comprises high-density, resting T cells. Recognition of autologous tumor cells by cytotoxic HD lymphocytes shares the characteristics of CTLs, i.e., their function is abrogated by pretreatment of the effectors with mAbs directed to the T3 receptor complex and by preincubation of the targets with mAb to the MHC class I antigens. Cytotoxicity of HD cells is restricted to the autologous tumor cells. This selectivity and the characteristics shared with CTL suggest that the auto-tumor reactivity of HD lymphocytes reflects an immune response against the autologous tumor.

Increased expression of MHC class I molecules on human cells after short time IFN-gamma treatment.

Human cell lines and blood lymphocytes were treated for short time periods with IFN-gamma. This treatment increased the amount of the assembled MHC class I molecules on the plasma membrane after 30 min. This early increase of the membrane expression subsided in the next few hours. A second wave of elevation occurred after 8-24 hr. Analysis of cytoplasmic and membrane molecules in pulse chase experiments showed that the cytokine enhanced both the assembly of available heavy and light chains and the transport of the complex to the plasma membrane. The membrane level of the HLA-A2 molecules showed similar kinetics. Addition of an A2 specific binding peptide stabilized the IFN-gamma induced molecules on the cell surface. It seems that IFN-gamma alone or together with a binding peptide can influence MHC class I expression solely through post-transcriptional events utilizing an available pool of free heavy and light chains already after a short time, before the enhancement of the synthesis starts.

Natural killer activity of human blood lymphocytes.

Natural killer (NK) activity is an operational designation. It implies the in vitro cytotoxicities registered in short-term tests exerted by lymphocytes derived from donors with no known immunization history against the particular target. The strength of the effect exerted by unmanipulated blood lymphocytes shows an individual variation. Short-term in vitro treatment with interferon elevates the lytic potential of lymphocytes. Owing to the heterogeneity of the cytotoxic blood lymphocytes with regard of cell surface properties it is not possible to separate all active cells and inactive cells in clean populations. A considerable enrichment of active cells can be achieved if nylon wool non-adherent, large, granular Fc gamma receptor positive SRBC receptor negative--or low-avidity SRBC receptor positive--OKM1-reactive cells are separated. Negative cells are concentrated in the Fc receptor and OKM1-negative high-avidity SRBC receptor positive high cell density subset. The activity of lymphocytes in the former category is potentiated by interferon and the latter acquire the lytic function if PHA is added to the assay system. Freshly separated, non-cultured tumor cells are not or weakly sensitive to the effect of unmanipulated lymphocytes. However, when the lymphocytes are treated with interferon prior to the assay a lytic potential can be induced even against these in allogeneic effector target combinations. Cytotoxic cells which acquired the function after in vivo and/or in vitro immunization are designated as 'cytotoxic T-lymphocytes' (CTL), and were shown to act on the basis of antigen recognition. The expression of known T-markers on at least a fraction of the active cells and the recognition of alloantigens in NK systems suggest that the distinction between CTL and NK cells is not as sharp as initially suggested.

Interferon-gamma and tumor necrosis factor-alpha treatment of ex vivo human carcinoma cells potentiates their interaction with allogeneic lymphocytes.

Short-term exposure of ex vivo carcinoma and sarcoma cells to IFN-gamma and TNF-alpha induced or elevated to detectable levels the surface expression of MHC class I, class II, and ICAM-1 (CD54), but only rarely the B7 (CD80) molecules. The cytokine-treated tumor cells interacted more efficiently with allogeneic blood lymphocytes collected from healthy donors compared with untreated cells. This was demonstrated (1) by the induction of DNA synthesis and generation of cytotoxic activity in mixed cultures and (2) by the elevated susceptibility to the cytotoxic effectors. Although the cytokine-induced increase in MHC and ICAM-1 on the low-expressor tumors were probably important to the interaction with lymphocytes, it is likely that other properties were also induced that contributed to the phenomenon. This was indicated by the results obtained with several tumors that expressed indigenously high levels of these molecules but reacted with the allogeneic lymphocytes only or more efficiently after treatment with IFN-gamma and TNF-alpha. In these experiments B7 expression did not influence the efficiency of interactions between lymphocyte and tumor cells. The results also showed that, under the conditions used, the untreated tumor cells that did not activate allogeneic lymphocytes were sensitive to appropriately activated effectors. Thus the afferent and efferent arms of lymphocyte-tumor cell interactions appeared to have different requirements.

Tumor surveillance: expression of the transporter associated with antigen processing (TAP-1) in ex-vivo human tumor samples and its elevation by in vitro treatment with IFN-gamma and TNF-alpha.

We have analyzed 30 human tumor specimens (two breast, six lung, and 21 ovarian carcinomas and one malignant melanoma) for the expression of the transporter associated with antigen processing, TAP-1. Cell suspensions judged to contain negligible contamination with non-tumor cells were tested for reactivity with the antibody directed to TAP-1 in Western blot. According to these results all lysates prepared from the tumor samples contained the protein, but with considerable quantitative variations. Tumors exposed in vitro for a short time to IFN-gamma and TNF-alpha had elevated TAP-1 levels in 12 out of 30 experiments. In accordance with previous results, the tumor cell populations were heterogeneous with regard to MHC class I expression, as analyzed by indirect immunofluorescence on viable cell suspensions. Short term in vitro treatment with IFN-gamma and TNF-alpha elevated MHC class I expression in several tumors. In several mixed cultures, cytokine treated tumor cells induced cytotoxic activity in autologous or allogeneic lymphocyte populations. In vitro treatment with IFN-gamma and TNF-alpha upregulated thus the expression of MHC class I and TAP-1 in a fraction of the tumor samples. However the potentiation of the capacity to interact with T cells induced by the cytokines was not always parallel with the changes in these two parameters. It is therefore likely that the cytokine treatment induced additional changes in the tumors which contributed to their capacity to elicit the T cell response.

Auto-tumor immunity in patients with solid tumors: participation of CD3 complex and MHC class I antigens in the lytic interaction.

In a number of experiments performed with blood lymphocytes of patients, the high density subset lysed autologous tumor cells separated from the surgical specimens. The lysis was abrogated by pretreatment of the effector cells with antibodies (OKT3) directed against the T3 molecule associated with the T cell receptor and by pretreatment of the target cells with antibodies (W6/32) directed against the monomorphic part of the MHC class I antigens. This subset lyses only autologous tumor cells. The selectivity and the characteristics shared with antigen specific cytotoxic T lymphocytes (CTL) suggest that the auto-tumor lysis by the effectors reflects an immune response against the tumor cells. The low density lymphocytes, separated from the blood, can lyse both auto- and allogeneic tumor cell. In the autologous system, incubation of the effectors with the mAb OKT3 had no inhibitory effect and incubation of the targets with the anti W6/32 mAb inhibited their lysis only in some experiments. The nature of the reactivity of the LD lymphocytes remains to be defined. Whether it is similar to the indiscriminative natural killing or whether part of these lymphocytes are antigen(s) specific and exhibit a high avidity interaction with the target remains to be seen. It is possible that both types of target recognition occur since the LD lymphocyte population is heterogeneous.

Predominant rearrangements of the T cell receptor beta-chain gene in blood lymphocyte populations stimulated with autologous tumor cells suggest clonal T cell expansion in two of fourteen cases.

T cell responses against autologous tumors with samples from patients with a variety of tumors were examined. The abilities of T lymphocytes to lyse the autologous tumor cells were analyzed after short-term mixed lymphocyte/tumor cell cultures (MLTC). Southern blot analysis was used to evaluate whether particular rearrangements of the TCR beta-chain gene predominate in these cultures. Tumor specific lysis could be induced in a proportion of the mixed cultures. In two cases enrichment of T lymphocytes with similar TCR beta-chain gene rearrangements was detected after repeated stimulations with autologous tumor cells.

Addition of a thiazide: an effective remedy for furosemide resistance after cardiac operations.

BACKGROUND: The frequent use of diuretic drugs in cardiac surgical practice contrasts with the lack of documentation regarding diuretic treatment in this setting. The aims of this study were to delineate the need for diuretic drugs in adult cardiac surgical practice and to evaluate the impact of adding a combination of 50 mg hydrochlorothiazide and 5 mg amiloride orally to patients responding poorly to furosemide. METHODS: Two hundred ten consecutive patients, 159 undergoing coronary artery bypass grafting procedures and 51 having valve operations, were studied. RESULTS: Seventy-seven patients received large doses of furosemide (> or = 80 mg/24 h) at some time during the postoperative course, and of these 20 responded poorly to furosemide (weight loss 0.3 +/- 0.2 kg) despite considerable fluid retention. The addition of hydrochlorothiazide and amiloride provided a prompt and effective remedy to relative furosemide resistance. Average weight loss was 2.3 +/- 0.2 kg (p < 0.01 compared with response to furosemide) and average diuresis was 2,949 +/- 156 mL in the following 24 hours. CONCLUSIONS: Relative furosemide resistance is common after cardiac operations. Thiazides, although they are mild diuretic agents, may serve as useful adjuncts in this setting.

Neurological injury after surgery for ischemic heart disease: risk factors, outcome and role of metabolic interventions.

OBJECTIVES: Neurological complication remains a feared and increasing problem in association with cardiac surgery. The aim of this study was to analyze risk factors for neurological complications in a cohort of patients in whom inotropes for weaning from cardiopulmonary bypass was gradually replaced by metabolic treatment. METHODS: The records of 775 consecutive patients undergoing coronary artery bypass grafting (CABG) or combined CABG+valve procedures were examined. Forward stepwise multiple logistic regression analysis was used for statistical evaluation of independent risk factors. RESULTS: The incidence of neurological injury was 1.8% in patients undergoing isolated CABG and 5.4% after combined CABG+valve procedures. After cross-validation multivariate analysis identified history of cerebrovascular disease, advanced age and aortic cross-clamp time as independent risk factors for postoperative cerebral complications. Chronic obstructive pulmonary disease and number of bypasses also emerged as risk factors in the primary analysis. CONCLUSIONS: In general, markers for advanced atherosclerosis, with history of cerebrovascular disease as the most important, emerged as predictors for neurological injury. Although it did not enter the final risk model, the results also suggest that postoperative heart failure deserves further surveillance as a potential risk factor for neurological complications. However, no evidence for untoward neurological effects associated with glutamate or glucose-insulin-potassium treatment was found.

Recognition of transformed cells by autologous lymphocytes: a review.

The studies on the T cell response against EBV carrying B cells demonstrated its high power in vivo. Malignancies with phenotypes similar to the in vitro transformed B cells occur only in severely immunosuppressed patients. Presently the goal of the studies is the identification of the antigens recognised by T lymphocytes and their association with the various HLA alleles. The studies on human sarcomas and carcinomas still struggle with the demonstration of specific T cell responses and the characterisation of the target molecules on the tumor cells. The main goals are the possibilities to readminister tumor reactive T cells for therapeutic purposes and the use of in vitro assays for guidance of the design and schedule for immunotherapy protocols.