Desmopressin after cardiac surgery in bleeding patients. A multicenter randomized trial.

BACKGROUND: Previous studies showed that desmopressin decreases post-operative blood loss in patients undergoing cardiac surgery. These studies were small and never studied the effect of desmopressin in patients with active bleeding. Objective of the study was to determine whether desmopressin reduces red blood cells transfusion requirements in patients with active bleeding after cardiac surgery who had been pre-treated with tranexamic acid. METHODS: This multicenter, randomized, double-blind, placebo-controlled, parallel-group study randomized elective patients with bleeding after cardiac surgery despite pre-treatment with tranexamic acid, to receive placebo (saline solution) or a single administration of desmopressin (0.3 µg/kg in saline solution). The primary endpoint was the number of patients requiring red blood cells transfusion after randomization and during hospital stay. Secondary end points were: blood loss from chest tubes during the first 24 h after study drug administration, hours of mechanical ventilation, intensive care unit stay, and in-hospital mortality. RESULTS: The study was interrupted after inclusion of 67% of the planned patients for futility. The number of patients requiring red blood cells transfusion after randomization was 37/68 (54%) in desmopressin group and 33/67 (49%) in placebo group (P = 0.34) with no difference in blood loss: 575 (interquartile 422-770) ml in desmopressin group and 590 (476-1013) ml in placebo group (P = 0.42), mechanical ventilation, intensive care unit stay or mortality. CONCLUSIONS: This multicenter randomized trial demonstrated that, in patients pre-treated with tranexamic acid, desmopressin should not be expected to improve treatment of patients who experience bleeding after cardiac surgery.

Sevoflurane vs. propofol in patients with coronary disease undergoing mitral surgery: a randomised study.

BACKGROUND: Myocardial ischemic damage is reduced by volatile anaesthetics in patients undergoing low-risk coronary artery bypass graft surgery; few and discordant results exist in other settings. We therefore performed a randomised controlled trial (sevoflurane vs. propofol) to compare cardiac troponin release in patients with coronary disease undergoing mitral surgery. METHODS: Patients with coronary artery disease undergoing mitral surgery were randomly allocated to receive either sevoflurane (50 patients) or propofol (50 patients) as main hypnotic. The primary endpoint of the study was peak post-operative cardiac troponin release defined as the maximum value among the post-operative values measured at intensive care unit arrival, 4 h later, on the first and second post-operative day. RESULTS: There was no significant difference in post-operative peak troponin release, the median (25th-75th percentiles) values being 14.9 (10.1-22.1) ng/ml and 14.5 (8.8-17.6) ng/ml in the sevoflurane and propofol groups, respectively (P = 0.4). Fentanyl administration was different between the two groups: 1347 ± 447 µg in patients receiving sevoflurane and 1670 ± 469 µg in those receiving propofol, P = 0.002. The 1-year follow-up identified two patients who died in the propofol group (one myocardial infarction and one low cardiac output syndrome) and one in the sevoflurane group (myocardial infarction). CONCLUSION: In this study, patients with coronary artery disease undergoing mitral surgery did not benefit from the cardioprotective properties of halogenated anaesthetics. Sevoflurane anaesthesia was not associated to lower cardiac troponin release when compared with propofol anaesthesia.

Transcriptional profile of denervated vastus lateralis muscle derived from a patient 8 months after spinal cord injury: a case-report.

A lack of motor neurons abolishes both neurotrophic factor secretion and contractile activity in muscle, which impairs mass, contractile properties, and fibre-type characteristics of the muscle. However, the molecular pathways that can be stimulated or repressed in the scenario of spinal cord injury remain unknown. We investigated for the first time the transcriptional profile of a young male patient 8 months after spinal cord injury. Adaptive metabolic changes of complete denervated skeletal muscle were revealed. In particular, the main molecular pathways involved include metabolic and proteolitic pathways, mitochondrial and synaptic function, calcium homeostasis, sarcomere and anchorage structures. Our data depict the molecular signalling still present in complete denervated skeletal muscle fibres a few months after spinal cord injury. These data could be of interest also to design a specific therapeutic approach aimed at the electrical-stimulation of severe atrophied skeletal muscle.

Cellular and molecular responses of human skeletal muscle exposed to hypoxic environment.

The effects of a hypobaric, hypoxic environment and exercise performed under extreme conditions, such as at high altitudes, are intriguing physiological aspects that need to be investigated directly on human climbers. Their skeletal muscle is one of the main tissues that can suffer from hypoxia and physical challenges, which will both define the muscle adaptation and the molecular signature of regenerative capacity. We investigated the muscle regenerative capacity characterizing satellite cells. Our study shows that satellite cells are altered by hypobaric, hypoxic environments and exercise performed at high altitudes. Of note, in human skeletal muscle after this 5,000 m a.s.l. expedition, SCs showed a significantly lower ability to regenerate skeletal muscle, in respect to before this high-altitude expedition. This impairment appears to be due to reduced satellite cell activity, consistent with their decreased myogenicity and fusion ability. Furthermore, at the transcriptional level several pathways, such as cell cycle, myogenesis, oxidative metabolism, proteolysis and sarcomeric protein synthesis, were found dysregulated.

Transcription profile analysis of vastus lateralis muscle from patients with chronic fatigue syndrome.

Chronic fatigue syndrome (CFS) is a disabling condition characterized by unexplained chronic fatigue that impairs normal activities. Many body systems are affected and etiology has not yet been identified. In addition to immunological and psychological aspects, skeletal muscle symptoms are prominent in CFS patients. In an effort to establish which pathways might be involved in the onset and development of muscle symptoms, we used global transcriptome analysis to identify genes that were differentially expressed in the vastus lateralis muscle of female and male CFS patients. We found that the expression of genes that play key roles in mitochondrial function and oxidative balance, including superoxide dismutase 2, were altered, as were genes involved in energy production, muscular trophism and fiber phenotype determination. Importantly, the expression of a gene encoding a component of the nicotinic cholinergic receptor binding site was reduced, suggesting impaired neuromuscular transmission. We argue that these major biological processes could be involved in and/or responsible for the muscle symptoms of CFS.

Functional characterization of muscle fibres from patients with chronic fatigue syndrome: case-control study.

Chronic fatigue syndrome (CFS) is a disabling condition characterized by unexplained chronic fatigue that impairs normal activities. Although immunological and psychological aspects are present, symptoms related to skeletal muscles, such as muscle soreness, fatigability and increased lactate accumulation, are prominent in CFS patients. In this case-control study, the phenotype of the same biopsy samples was analyzed by determining i) fibre-type proportion using myosin isoforms as fibre type molecular marker and gel electrophoresis as a tool to separate and quantify myosin isoforms, and ii) contractile properties of manually dissected, chemically made permeable and calcium-activated single muscle fibres. The results showed that fibre-type proportion was significantly altered in CSF samples, which showed a shift from the slow- to the fast-twitch phenotype. Cross sectional area, force, maximum shortening velocity and calcium sensitivity were not significantly changed in single muscle fibres from CSF samples. Thus, the contractile properties of muscle fibres were preserved but their proportion was changed, with an increase in the more fatigue-prone, energetically expensive fast fibre type. Taken together, these results support the view that muscle tissue is directly involved in the pathogenesis of CSF and it might contribute to the early onset of fatigue typical of the skeletal muscles of CFS patients.

Effects of tiredness on visuo-spatial attention processes in elite karate athletes and non-athletes.

"Attentional" adaptations are fundamental effects for sport performance. We tested the hypothesis that tiredness and muscular fatigue poorly affect visuo-spatial attentional processes in elite karate athletes. To this aim, 14 elite karate athletes and 11 non-athletes were involved in an isometric contraction exercise protocol up to muscular fatigue. Blood lactate and attention measurements were taken. Posner's test probed "endogenous" (i.e., internally planned allocation of spatial attention) and "reflexive" (i.e., brisk variation of endogenous spatial attention due to unexpected external stimuli) attention. Lactate and attentional measurements were performed before (Block 1, B1) and after the fatiguing exercise (B2) and at the end of a recovery period (B3). Compared to the non-athletes, the athletes showed a better performance in the fatigue protocol, confirmed by the higher absolute lactate values in B2. The correct responses in the "valid trials" probing "endogenous" attention were 92.4% (B1), 93.9% (B2), and 95.8% (B3) in the non-athletes, and 98.5%, 96.4%, 95.5% in the elite karate athletes. The correct responses in the "invalid trials" probing "reflexive" attention were 95.4%, 89.7%, 93.2% in the non-athletes, and 96.4%, 97.3%, 98.5% in the elite karate athletes. The percentage of correct responses in the "invalid" trials significantly decreased from B1 to B2 in the non-athletes but not in the elite karate athletes. In conclusion, tiredness and muscular fatigue do not affect "reflexive" attentional processes of elite karate athletes, which is crucial to contrast attacks coming from an unexpected spatial region.

Age-dependent effects on functional aspects in human satellite cells.

In humans aging is a complex process that determines many physical and metabolic alterations correlated to the accumulation of oxidative damage in different tissues. Sarcopenia is an age-related nonpathological condition that includes a progressive loss of mass and strength in skeletal muscle, associated with a decline in the fibers' functional capability. This condition could be correlated to abnormal reactive oxygen species (ROS) accumulation with consequent fiber oxidative damage. This complex situation is not only evident in mature muscle fibers but also in muscle resident satellite cells (involved in fiber damage repairing) in which some functional parameters, at least for that concerns the Ca(2+) homeostasis, seem to be modified. In fact, our data show that there is an age-dependent increase of lipid peroxidation, in cultured myotubes (differentiated and fused satellite cells) after 7 days of in vitro differentiation. In these substrates also the capacity of these cells to produce Ca(2+) transient in response to various stimuli (ATP, caffeine, nicotine, KCl) is, sometimes, drastically modified. In particular, the presence of an age-dependent defective status of excitation-contraction (EC) coupling apparatus is supported by a single cell Ca(2+) analysis obtained from myotubes (derived from aged muscles) in the presence of 40 mM caffeine or 40 mM KCl. The alkaloid presence induces a complete emptying of ryanodine-dependent calcium stores indicating a probable integrity both of SR-terminal cisternae and/or the specific Ca(2+) channel known as RyR1. However, if a sarcolemmal depolarization is induced by the addition of 40 mM KCl in the experimental medium then Ca(2+) release RyR1-dependent can be observed only if Ca(2+) is present in the experimental solution. These results suggest that the EC uncoupling status could be due to the alteration of the interaction between RyR and DHPR. The two receptors are present and functionally active in myotubes from aged donors but they are probably still not in the right localization. These results suggest that during donor's life the satellite cells undergo an aging process similar to the one observed in skeletal muscle tissue, even if they are in a quiescence status for most of the time.

The S-100: a protein family in search of a function.

The S-100 is a group of low molecular weight (10-12 kD) calcium-binding proteins highly conserved among vertebrates. It is present in different tissues as dimers of homologous or different subunits (alpha, beta). In the nervous system, the S-100 exists as a mixture composed of beta beta and alpha beta dimers with the monomer beta represented more often. Its intracellular localisation is mainly restricted to the glial cytoplasmic compartment with a small fraction bound to membranes. In this compartment the S-100 acts as a potent inhibitor of phosphorylation on several substrates including the synaptosomal C-Kinase and Tau, a microtubule-associated protein. The S-100 in particular conditions, after binding with specific membrane sites (Kd = 0.2 microM; Bmax = 4.5 nM), is able to modify the activity of adenylate cyclase, probably via G-proteins. In addition, the Ca2+ homeostasis is also modulated by S-100 via an increase of specific membrane conductance and/or Ca2+ release from intracellular stores. "In vitro" and "in vivo" experiments showed that lower (nM) concentrations of extracellular S-100 beta act on glial and neuronal cells as a growth-differentiating factor. On the other hand, higher concentrations of the protein induce apoptosis of some cells such as the sympathetic-like PC12 line. Finally, data obtained from physiological (development, ageing) or pathological (dementia associated with Down's syndrome, Alzheimer's disease) conditions showed that a relationship could be established between the S-100 levels and some aspects of the statii.

Double effect of ethanol on intracellular Ca2+ levels in undifferentiated PC12 cells.

In PC12, a cellular line derived from a rat pheochromocytoma, ethanol (EtOH) induces a different effect depending on the concentration used. When resting cells are incubated with an alcohol concentration less than or equal to 120 mM, the [Ca2+]i increased with a double phase pattern. If the alcohol concentration was increased over 120-160 mM, EtOH reversed its effect and the [Ca2+]i decreased. This decrease was strongly inhibited if KCl-depolarized cells were used and was completely abolished if the substrate constituted EtOH-chronically treated cells. The Ca2+ increase is the consequence of an activation of L-type voltage-activated channels, while the other voltage-dependent channels (N-type), the receptor-operated channels and the Ca2+ extrusion pump present in these cells are not involved in EtOH action. These findings indicate that EtOH can induce (by different mechanisms) both potentiating and inhibiting effects on [Ca2+]i in PC12 cells in relation to the alcohol dose effectively present in the suspension medium.

Alteration of membrane transductive mechanisms induced by ethanol in human lymphocyte cultures.

Ethanol, in millimolar concentrations, significantly modifies different transductive systems in human lymphocyte cultures. In particular, the presence of alcohol in the medium more than doubles the [Ca2+]i (from 70-90 to 200-250 nM), increasing Ca2+ fluxes from outside, and inhibits the active transport carried out by the calcium pump. The Ca2+ release from intracellular stores is not involved because 10 mM EGTA in the medium completely abolished the rise of [Ca2+]i. Since IP3 levels and cAMP concentrations are also involved in ethanol events (although with opposite effects), it seems that the alcohol may have a specific target on cell membranes (G-proteins) which influence many transductive pathways.

S-100b protein regulates the activity of skeletal muscle adenylate cyclase in vitro.

We have investigated the effect of the b isoform of S-100 proteins on adenylate cyclase activity of rat skeletal muscle. S-100b inhibits the adenylate cyclase activity in the presence of Mg2+ (5.0-50 mM), while it activates the same enzyme in the presence of Ca2+ (0.1-1.0 mM) dose-dependently in both cases. S-100b counteracts the stimulatory effect of NaF on adenylate cyclase in the presence of Mg2+ and the inhibitory effect of RMI 12330 A in the presence of Ca2+.

S-100a0 protein stimulates the basal (Mg2+-activated) adenylate cyclase activity associated with skeletal muscle membranes.

S-100a0 protein, the alpha alpha isoform of the S-100 family, stimulates basal (Mg2+-activated) adenylate cyclase (AC) activity associated with the sarcolemma, longitudinal tubules and terminal cisternae of rat skeletal muscle cells. The stimulatory effect of S-100a0 on AC activity is maximal around 5 microM S-100a0 and half-maximal around 0.2 microM S-100a0. Also, the stimulatory effect is greatest on the AC activity associated with the terminal cisternae than on the other membrane fractions studied. These data are discussed in relation to the subcellular localization of S-100a0 in muscle cells.

S-100a0 protein stimulates Ca2+-induced Ca2+ release from isolated sarcoplasmic reticulum vesicles.

S-100a0 protein, the alpha alpha-isoform of the S-100 family, stimulates Ca2+-induced Ca2+ release from terminal cisternae isolated from rat skeletal muscle cells. The stimulatory effect of S-100a0 is maximal at approximately 5 microM S-100a0 and half maximal at approximately 0.1 microM S-100a0, at 1.8 microM free Ca2+ in the presence of 5 mM Mg2+ plus 0.1 M KCl. The effect of the protein on Ca2+-induced Ca2+ release is completely inhibited by the calcium release blocker, ruthenium red.

Specific oxidative alterations in vastus lateralis muscle of patients with the diagnosis of chronic fatigue syndrome.

Chronic fatigue syndrome (CFS) is a poorly understood disease characterized by mental and physical fatigue, most often observed in young white females. Muscle pain at rest, exacerbated by exercise, is a common symptom. Although a specific defect in muscle metabolism has not been clearly defined, yet several studies report altered oxidative metabolism. In this study, we detected oxidative damage to DNA and lipids in muscle specimens of CFS patients as compared to age-matched controls, as well as increased activity of the antioxidant enzymes catalase, glutathione peroxidase, and transferase, and increases in total glutathione plasma levels. From these results we hypothesize that in CFS there is oxidative stress in muscle, which results in an increase in antioxidant defenses. Furthermore, in muscle membranes, fluidity and fatty acid composition are significantly different in specimens from CFS patients as compared to controls and to patients suffering from fibromyalgia. These data support an organic origin of CFS, in which muscle suffers oxidative damage.

Age-dependent increases in oxidative damage to DNA, lipids, and proteins in human skeletal muscle.

A role for oxidative damage in normal aging is supported by studies in experimental animals, but there is limited evidence in man. We examined markers of oxidative damage to DNA, lipids, and proteins in 66 muscle biopsy specimens from humans aged 25 to 93 years. There were age-dependent increases in 8-hydroxy-2-deoxyguanosine (OH8dG), a marker of oxidative damage to DNA, in malondialdehyde (MDA), a marker of lipid peroxidation, and to a lesser extent in protein carbonyl groups, a marker of protein oxidation. The increases in OH8dG were significantly correlated with increases in MDA. These results provide evidence for a role of oxidative damage in human aging which may contribute to age-dependent losses of muscle strength and stamina.

Cooperation in signal transduction of extracellular guanosine 5' triphosphate and nerve growth factor in neuronal differentiation of PC12 cells.

Guanosine 5' triphosphate (GTP), acting synergistically with the nerve growth factor (NGF), enhances the proportion of neurite-bearing cells in cultures of PC12 rat pheochromocytoma cells. We studied the transduction mechanisms activated by GTP in PC12 cells and found that addition of GTP (100 microM) increased intracellular calcium concentration ([Ca(2+)](i)) in cells that were between 60 and 70% confluent. Addition of GTP also enhanced activation of NGF-induced extracellular regulated kinases (ERKs) and induced Ca(2+) mobilization. This mobilization, due to the activation of voltage-sensitive and ryanodine-sensitive calcium channels, as well as pertussis toxin-sensitive purinoceptors, modulates Ca(2+)-activated K(+) channels not involved in activation of ERKs. The results presented here indicate that GTP-triggered [Ca(2+)](i) increase may be a key event in GTP signal transduction, which can modulate activity of ERKs. The physiological importance of the GTP effect lies in its capacity to interact with the NGF-activated pathway to enhance neurite outgrowth from PC12 cells.

Nerve growth factor inhibits apoptosis induced by S-100 binding in neuronal PC12 cells.

When grown for seven days in a medium containing nerve growth factor (100 ng/ml), 10% horse serum and 5% fetal bovine serum PC12 cells stopped dividing, extended neurites and assumed a neuronal phenotype. Withdrawal of nerve growth factor from these cells resulted in loss of neurites and apoptotic changes in many cells. The apoptotic changes were exacerbated if the cells were also exposed to 1-2 microM S-100, a calcium binding protein purified from bovine brain. After exposure to S-100, the PC12 cells underwent characteristic apoptotic changes. Within 2 in neurites retracted, the cell body shrunk and submembranous accumulation of condensed cytoplasmic material was observed. DNA ladders were present after 24-48 h and 60% of the cells became hypodiploid after 72 h. S-100 induced apoptosis by binding to specific sites (Kd = 189 nM) on PC12 cells and this caused a rise in [Ca2+]i due to a transmembrane capacitative flux followed by the depletion of internal stores. This increase was reversed if 5 microM nifedipine, a specific L-type Ca2+ channel inhibitor, was added to the medium after S-100 and completely abolished if the cells were pretreated with 5 microM thapsigargin, an inhibitor of endoplasmic reticulum Ca(2+)-ATPase. The presence of nerve growth factor in the culture medium completely blocked the apoptotic changes induced by S-100, probably due to interaction of nerve growth factor and S-100 at the same binding sites. These data indicate that nerve growth factor not only prevents apoptosis during cell development, but also apoptosis induced by endogenous substances such as S-100.

The brain protein S-100ab induces apoptosis in PC12 cells.

Incubation of PC12 cells with S-100 protein induces a rapid (0.5-1.0 min) rise of intracellular Ca2+ which lasts for the whole period of incubation. This effect is abolished in a Ca(2+)-free medium or in the presence of 1.0 microM Ni2+, an inhibitor of calcium channels. The rise in intracellular Ca2+ is followed by a progressive increase of cells undergoing degeneration and death. This event is accompanied by the appearance of apoptotic bodies and DNA fragmentation typical of the process known as apoptosis. S-100-induced cell death is prevented by 1 microM Ni2+ or by 0.1 nM cycloheximide, suggesting the involvement of new protein synthesis. It is postulated that the binding of S-100ab to specific sites present in PC12 cells is followed by the formation of Ca2+ channels and/or the stimulation of pre-existing ones with consequent increase of Ca2+ influx and activation of a process of cell death.

Extracellular guanosine 5' triphosphate enhances nerve growth factor-induced neurite outgrowth via increases in intracellular calcium.

Extracellular guanosine 5' triphosphate (GTP) enhances nerve growth factor-dependent neurite outgrowth from rat pheochromocytoma (PC12) cells; cultures of PC12 cells exposed to GTP and nerve growth factor together contain significantly more neurite-bearing cells than do those exposed to either nerve growth factor or GTP alone [Gysbers J. W. and Rathbone M. P. (1996) Int. J. devl Neurosci. 14, 19-34]. PC12 cells contain specific cell surface binding sites for extracellular GTP, which do not bind ATP or uridine 5' triphosphate. Exposure of PC12 cells to extracellular GTP (300microM) produced a robust and sustained increase in intracellular Ca(2+) ([Ca(2+)](i)), different from the transient response to the addition of ATP. The GTP-induced [Ca(2+)](i) increase was blocked by the L-type calcium channel inhibitor, nifedipine. The L-type Ca(2+) channel inhibitors, nifedipine or verapamil, also inhibited the enhancement of neurite outgrowth by GTP, but did not affect neurite outgrowth stimulated by nerve growth factor alone. Pre-treatment of PC12 cells with ryanodine (0.5-50microM) depleted calcium from internal stores and prevented the further release of calcium by GTP. Similarly, pre-treatment of PC12 cells with thapsigargin (an inhibitor of internal store Ca(2+)/ATPase) or dantrolene (which blocks Ca(2+) release from some of these stores) also reduced the enhancement of neurite outgrowth by GTP. Therefore, Ca(2+)-induced Ca(2+) release from specific stores, present in PC12 cells, is involved in the enhancement of nerve growth factor-induced neurite outgrowth by GTP, possibly acting at specific binding sites on the cell surface. GTP is proving to be an important extracellular trophic modulator in the central nervous system. These studies show that the neuritogenic actions of GTP involve moderate but sustained increases in intracellular Ca(2+) which are likely due to activation of L-type Ca(2+) channels and Ca(2+)-induced Ca(2+) release from intracellular stores. These effects of extracellular GTP are likely mediated at the cell surface and may be related to specific GTP binding sites which are distinct from G-proteins and from hitherto described purine nucleotide (P2) receptors. These data indicate a mechanism whereby the neuritogenic effects of GTP are mediated and emphasize the importance of considering GTP as a neurotrophic mediator.