Effects of antegrade and retrograde machine perfusion preservation on cardiac function after transplantation in canines.

INTRODUCTION: Most studies investigating machine perfusion preservation for heart transplantation perfuse through the aortic root (antegrade), but the coronary sinus (retrograde) is a potential option. We hypothesized that retrograde machine perfusion provides better functional protection than static storage, while avoiding the potential irregular perfusion seen when aortic insufficiency occurs with antegrade perfusion. MATERIALS AND METHODS: Eighteen canine donor hearts were arrested, procured, and stored in modified Celsior solution for 4 hours by using either static storage at 0°C to 4°C (n = 6) or machine perfusion preservation at 5°C via the aortic root (antegrade, n = 6) or coronary sinus (retrograde, n = 6). Lactate and myocardial oxygen consumption were measured in perfused hearts. Hearts were reimplanted and reperfused for 6 hours with hourly function calculated by using the preload recruitable stroke work (PRSW) relation. Myocardial water content was determined at the end of the experiment. RESULTS: Storage lactate levels and myocardial oxygen consumption were comparable in both perfused groups. The PRSW was increased immediately after bypass in the antegrade group (120.6 ± 19.1 mm Hg) compared with the retrograde (75.0 ± 11.3 mm Hg) and static (78.1 ± 10.5 mm Hg) storage groups (P < .05). At the end of reperfusion, PRSW was higher in the retrograde group (69.8 ± 7.4 mm Hg) compared with the antegrade (40.1 ± 6.8 mm Hg) and static (39.9 ± 10.9 mm Hg) storage groups (P < .05). Myocardial water content was similar among groups. CONCLUSIONS: Both antegrade and retrograde perfusion demonstrated excellent functional preservation, at least equivalent to static storage. Initial function was superior in the antegrade group, but the retrograde hearts displayed better function late after reperfusion. Neither perfused group developed significant edema. Machine perfusion preservation is a promising technique for improving results of cardiac transplantation.

Circadian periodicity of intestinal Na+/glucose cotransporter 1 mRNA levels is transcriptionally regulated.

Intestinal expression of the high affinity Na+/glucose cotransporter 1 (SGLT1), which absorbs dietary glucose and galactose, exhibits both circadian periodicity in its activity and induction by dietary carbohydrate. Because the daily variation in SGLT1 activity is established by the feeding schedule (whether ad libitum or imposed) and persists in the absence of food, this variation has been described as anticipatory. To delineate the mechanisms regulating SGLT1, its expression was examined in rats maintained in a 12-h photoperiod with free access to chow. SGLT1 mRNA levels varied significantly, with the maximum abundance occurring near the onset of dark and the minimum near the onset of light. The SGLT1 transcription rate was 7-fold higher in the morning (1000-1100 h) than in the afternoon (1600-1700 h). An element for hepatocyte nuclear factor 1 (HNF-1) was identified in the SGLT1 promoter that formed different complexes with small intestinal nuclear extracts, depending on the time when the source animal was killed. Serological tests indicated that HNF-1alpha was present in complexes throughout the day, while HNF-1beta binding exhibited circadian periodicity. We propose that exchange of HNF-1 dimerization partners contributes to circadian changes in SGLT1 transcription. Because SGLT1 mRNA levels also varied in rhesus monkeys (offset by approximately one-half day from rats), a similar mechanism appears to be present in primates.

Treatment of large subchondral tumors of the knee with cryosurgery and composite reconstruction.

The radiographic and clinical outcomes of 9 patients with large benign aggressive or low-grade malignant periarticular tumors of the knee who were treated with cryosurgery and composite reconstruction (cementation, bone graft, and internal fixation) in lieu of primary resection were analyzed. The minimum followup was 2 years (range, 24-103 months). There were 6 giant cell tumors and a single case each of chondroblastoma, chondrosarcoma, and fibrosarcoma in the study group. Six lesions involved the distal femur and 3 the proximal tibia. Functional outcomes were graded according to the Enneking Modified System for the Functional Evaluation of Tumor and The Knee Rating Scale of The Hospital for Special Surgery. All lesions extended to within 2 mm of the articular surface. Local tumor control was achieved in 8 patients (89%). The single local recurrence was successfully managed with repeat curettage, cryosurgery, cementation, and internal fixation. All 9 patients had excellent functional outcomes according to both evaluation scales.

Comparative bioavailability of a generic phenytoin and Dilantin.

Generic substitution of antiepileptic drugs (AEDs) has been controversial, with many alleged instances of biologic and therapeutic inequivalence reported. The recall of a generic phenytoin (PHT) formulation used in the Veterans Administration (VA) medical system allowed us to evaluate the question of biologic equivalence systematically in a relatively large number of patients at the Bronx VA Medical Center. Serum PHT levels were 22-31% lower during the period of generic intake as compared with levels in the same patients receiving Dilantin. Review of the literature showed only one other adequately documented report of potential clinically significant inequivalence between a brand name and generic AED. Despite the apparent infrequency of generic inequivalence, several areas in which procedures for certification of therapeutic equivalence should be improved were identified.

SCID diagnosis of panic disorder in psychogenic seizure patients.

The authors administered the Structured Clinic Interview for DSM-III-R (SCID) to 20 outpatients with nonepileptic seizures documented by video-EEG. Fourteen (70%) had one or more non-somatoform DSM-III-R diagnoses. All 14 met criteria for panic disorder. Comorbid mood, psychotic, substance abuse, and eating disorders were also noted. Meticulous use of the SCID, with extensive follow-up, may have resulted in enhanced detection of panic disorder in patients who do not spontaneously report panic symptoms. Panic attacks may play a more important role in nonepileptic seizures than has been generally recognized, especially in outpatients with a chronic course of illness.

Facilitating difficult catheter passage.

Passage of a flexible catheter into a septic flexor tendon sheath can be difficult and time consuming because of the catheter's pliability. This article discusses a technique for converting the flexible catheter into a semirigid stylet.

Early sarcomatous degeneration near a cementless hip replacement. A case report and review.

We present the case of a 65-year-old man who developed a malignant fibrous histiocytoma at the lesser trochanter five months after a cementless hip replacement. We have reviewed reports of similar cases and discuss them in terms of the possible mechanisms of sarcomatous degeneration and the latency of such changes.

Imaging rounds. Synovial chondromatosis.

The following case is presented to illustrate the roentgenographic and clinical findings of a condition of interest to the orthopaedic surgeon. Initial history, physical findings, and roentgenograms are found on the first two pages. The following pages present the final clinical and roentgenographic differential diagnosis.

Nonoperative management of herniated nucleus pulposus: patient selection by the extension sign. Long-term follow-up.

We have previously reported that the ability of patients with herniated nucleus pulposus (HNP) and radiculopathy to achieve full passive lumbar extension (negative extension sign) is a useful predictor of favorable response to conservative management. Of 154 patients with back pain and radiculopathy seen between 1979 and 1985, 73 were selected for conservative management based on this criterion. We also reviewed results of electromyography (EMG), computed tomography (CT), myelography, straight leg raise, crossed straight leg raise, deep tendon reflex, and dermatomal-sensory and motor deficits. Ninety-four percent of the subjects achieved full extension within 5 days of hospital admission. Although some patients who had full extension on admission subsequently underwent chemonucleolysis or surgery, none of those who could not extend initially and who later gained full lumbar extension required surgery. Of the 33 patients who were available for long-term follow-up, 94% were satisfied with the results, 82% were able to resume working, 73% required no analgesics, and 9% later required chemonucleolysis or surgery. Positive findings on admission EMG (5 of 7 patients), myelography (5 of 8 patients), or CT (9 of 11) did not preclude good results with conservative management. Female patients without complaint at follow-up (53%) outnumbered their male counterparts (25%). Patients (19 of 33) whose extension sign was initially positive on admission and became negative within 5 days of hospitalization (average, 1.6 days) had better outcomes with 95% satisfied, 90% without job changes, 74% not requiring analgesia, and none requiring surgery. At long-term follow-up, the extension sign effectively predicted a favorable response to nonoperative therapy of HNP in 91% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperglycemia presenting with occipital seizures.

Seizures are common in hyperglycemia and are often the first manifestation, particularly in nonketotic hyperglycemia (NKH). Published reports emphasize partial motor seizures almost exclusively. In a 3-year period, we observed three patients in whom occipital seizures, documented by ictal EEG recording, were the initial symptom of hyperglycemia. One patient was mildly ketotic at first. Seizures were visual in two patients and visual and adversive in the third. Seizures regressed with correction of abnormal glucose levels and did not recur during follow-up of less than or equal to 1 year despite discontinuation of antiepileptic drugs (AEDs) in two. Computed tomography (CT) scans did not show correlative abnormalities. Although published reports suggest that frontal lobe structures are particularly susceptible to the epileptogenic effects of NKH, our experience indicates that in NKH epileptic foci may originate in other cortical areas, such as occipital.

Unilateral truncal seizures: frontal origin.

The locus of origin of seizures involving the muscles of the trunk is unresolved. The brainstem has been postulated by some investigators, whereas others have implicated the parietal cortex. We report a patient with epilepsia partialis continua involving the rectus abdominus of one side in whom each contraction correlated with an epileptiform complex in the contralateral central-vertex scalp region. This appears to be the first instance in which ictal EEG has localized truncal seizures to an area that probably corresponds to the precentral cortex.

Daytime intensive monitoring: comparison with prolonged intensive and ambulatory monitoring.

We evaluated daytime (6- to 8-hour) intensive monitoring in a consecutive series of 166 studies. Overall success rate in answering clinical questions posed by referring physicians was 67%, and attacks were recorded in 55%. Daytime intensive monitoring provides a useful, cost-effective alternative to prolonged inpatient monitoring and ambulatory monitoring.

Epileptic aphasia.

We document a case of isolated epileptic aphasia with clear correlation between episodic clinical and electrographic events. This disorder is rarely recognized, perhaps because it is obscured by ictal motor activity or speech arrest, or by the lack of clinical manifestations if the seizure occurs when the patient is not attempting to speak.

Contraversive seizures in occipital epilepsy: case report and review of the literature.

We studied a man with repeated seizures characterized by deviation of the head and eyes to the left. A right occipital focus was demonstrated in the EEG. Adversion is usually associated with frontal or temporal lobe seizures; the direction of adversion is equally likely to be ipsilateral as contralateral to the ictal focus. In all reports of occipital epilepsy, the ictal focus has been contralateral to the direction of head turning.

The syndrome of painful ophthalmoplegia. A case with intraorbital mass and hypervascularity.

A patient diagnosed as having Tolosa-Hunt syndrome on clinical grounds was found by arteriography to have an intraorbital mass with hypervascularity. To our knowledge, this radiologic finding has not previously been reported in either Tolosa-Hunt syndrome or in the syndrome of orbital pseudotumor, and supports the proposition that these two conditions are anatomical variants of the same pathological process.