Costs and quality of life associated with radial artery and saphenous vein cardiac bypass surgery: results from a Veterans Affairs multisite trial.

BACKGROUND: In coronary artery bypass grafting (CABG) surgery, there is uncertainty about whether the radial artery affects quality of life or costs relative to the saphenous vein. This study compared the cost and quality of life for patients randomized to either radial artery or saphenous vein grafts. METHODS: We analyzed the duration and cost of the index surgery and costs and quality of life (Seattle Angina Questionnaire and Health Utility Index) at 1 year for 726 participants. RESULTS: The 2 treatment groups had similar baseline characteristics. Using the radial artery added approximately 31 minutes to the surgery (from skin incision to skin closure; P < .001) compared with a saphenous vein graft. There were no significant differences in terms of costs and quality of life after the index hospitalization or at 1 year. CONCLUSIONS: Coronary artery bypass grafting with the radial artery lasts approximately 31 minutes longer than with the saphenous vein. However, costs and the quality of life were not statistically different.

A rupture of both atrioventricular valves after blunt chest trauma: the usefulness of transesophageal echocardiography for a life-saving diagnosis.

Survival after the rupture of the both mitral and tricuspid valves in blunt thoracic trauma is uncommon and requires prompt diagnosis and treatment. We present a case in which transesophageal echocardiography performed in the operating room by the anesthesiologist identified the etiology of hemodynamic instability and facilitated successful emergency replacement of both valves.

The C. elegans Mi-2 chromatin-remodelling proteins function in vulval cell fate determination.

The Mi-2 protein is the central component of the recently isolated NuRD nucleosome remodelling and histone deacetylase complex. Although the NuRD complex has been the subject of extensive biochemical analyses, little is known about its biological function. Here we show that the two C. elegans Mi-2 homologues, LET-418 and CHD-3, play essential roles during development. The two proteins possess both shared and unique functions during vulval cell fate determination, including antagonism of the Ras signalling pathway required for vulval cell fate induction and the proper execution of the 2 degrees cell fate of vulval precursor cells, a process under the control of LIN-12 Notch signalling.

Chromatin diminution in the parasitic nematodes ascaris suum and parascaris univalens.

Chromatin diminution in Parascaris univalens and Ascaris suum undoubtedly represents an interesting case of developmentally programmed DNA rearrangement in higher eukaryotes. It is a complex mechanism involving chromosomal breakage, new telomere addition and DNA degradation, and occurs in all presomatic cells. The process is rather specific with respect to its developmental timing and the chromosomal regions that are eliminated. The functional significance of chromatin diminution still remains an enigma. The fact, however, that single-copy, protein-coding genes are contained in the eliminated DNA demonstrates that in P. univalens and A. suum, there is a qualitative difference between germ-line and somatic genomes, and suggests that chromatin diminution may be used as a "throw-away" approach to gene regulation. We present a hypothesis as to how, during evolution, a partial genome duplication might have been linked to the process of chromatin diminution, in order to provide a selective advantage to parasitic DNA-eliminating nematodes.

Developmentally regulated telomerase activity is correlated with chromosomal healing during chromatin diminution in Ascaris suum.

Telomerase is the ribonucleoprotein complex responsible for the maintenance of the physical ends, or telomeres, of most eukaryotic chromosomes. In this study, telomerase activity has been identified in cell extracts from the nematode Ascaris suum. This parasitic nematode is particularly suited as a model system for the study of telomerase, because it shows the phenomenon of chromatin diminution, consisting of developmentally programmed chromosomal breakage, DNA elimination, and new telomere formation. In vitro, the A. suum telomerase is capable of efficiently recognizing and elongating nontelomeric primers with nematode-specific telomere repeats by using limited homology at the 3' end of the DNA to anneal with the putative telomerase RNA template. The activity of this enzyme is developmentally regulated, and it correlates temporally with the phenomenon of chromatin diminution. It is up-regulated during the first two rounds of embryonic cell divisions, to reach a peak in 4-cell-stage embryos, when three presomatic blastomeres prepare for chromatin diminution. The activity remains high until the beginning of gastrulation, when the last of the presomatic cells undergoes chromatin diminution, and then constantly decreases during further development. In summary, our data strongly argue for a role of this enzyme in chromosome healing during the process of chromatin diminution.

Anterior organization of the Caenorhabditis elegans embryo by the labial-like Hox gene ceh-13.

The Caenorhabditis elegans lin-39, mab-5 and egl-5 Hox genes specify cell fates along the anterior-posterior body axis of the nematode during postembryonic development, but little is known about Hox gene functions during embryogenesis. Here, we show that the C. elegans labial-like gene ceh-13 is expressed in cells of many different tissues and lineages and that the rostral boundary of its expression domain is anterior to those of the other Hox genes. By transposon-mediated mutagenesis, we isolated a zygotic recessive ceh-13 loss-of-function allele, sw1, that exhibits an embryonic sublethal phenotype. Lineage analyses and immunostainings revealed defects in the organization of the anterior lateral epidermis and anterior body wall muscle cells. The epidermal and mesodermal identity of these cells, however, is correctly specified. ceh-13(sw1) mutant embryos also show fusion and adhesion defects in ectodermal cells. This suggests that ceh-13 plays a role in the anterior organization of the C. elegans embryo and is involved in the regulation of cell affinities.

The expression of the C. elegans labial-like Hox gene ceh-13 during early embryogenesis relies on cell fate and on anteroposterior cell polarity.

Clusters of homeobox-containing HOM-C/hox genes determine the morphology of animal body plans and body parts and are thought to mediate positional information. Here, we describe the onset of embryonic expression of ceh-13, the Caenorhabditis elegans orthologue of the Drosophila labial gene, which is the earliest gene of the C. elegans Hox gene cluster to be activated in C. elegans development. At the beginning of gastrulation, ceh-13 is asymmetrically expressed in posterior daughters of anteroposterior divisions, first in the posterior daughter of the intestinal precursor cell E and then in all posterior daughters of the AB descendants ABxxx. In this paper, we present evidence that supports position-independent activation of ceh-13 during early C. elegans embryogenesis, which integrates cell fate determinants and cell polarity cues. Our findings imply that mechanisms other than cell-extrinsic anteroposterior positional signals play an important role in the activation and regulation of the C. elegans Hox gene ceh-13.

cec-1, a soma-specific chromobox-containing gene in C. elegans.

The chromo domain is a phylogenetically conserved sequence motif which was identified as a region of homology between the repressor protein Pc and the heterochromatin constitutive protein HP1 of Drosophila. The specific function of the chromo domain is not yet understood, but it seems to be required for protein-protein interactions in chromatin-associated complexes. Here, we present a new chromobox-containing gene from Caenorhabditis elegans (cec-1). It encodes a nuclear protein that is present in all somatic cells from the 50- to 80-cell stage on throughout development and in adult animals. No cec-1 protein was detected in the cells of early embryos, in germ cells, and in their precursor cells Z2 and Z3. cec-1 mRNA, however, is already present in all the blastomeres of early embryos. Immunolocalization experiments revealed a homogeneous distribution of CEC-1 within interphase nuclei, while during mitosis CEC-1 seems to dissociate from the condensing chromosomes. The expression pattern of the cec-1 gene suggests that it may represent a new regulatory gene in C. elegans.

Telomeric repeats (TTAGGC)n are sufficient for chromosome capping function in Caenorhabditis elegans.

Telomeres are specialized structures located at the ends of linear eukaryotic chromosomes that ensure their complete replication and protect them from fusion and degradation. We report here the characterization of the telomeres of the nematode Caenorhabditis elegans. We show that the chromosomes terminate in 4-9 kb of tandem repeats of the sequence TTAGGC. Furthermore, we have isolated clones corresponding to 11 of the 12 C. elegans telomeres. Their subtelomeric sequences are all different from each other, demonstrating that the terminal TTAGGC repeats are sufficient for general chromosomal capping functions. Finally, we demonstrate that the me8 meiotic mutant, which is defective in X chromosome crossing over and segregation, bears a terminal deficiency, that was healed by the addition of telomeric repeats, presumably by the activity of a telomerase enzyme. The 11 cloned telomeres represent an important advance for the completion of the physical map and for the determination of the entire sequence of the C. elegans genome.

Chromatin diminution in nematodes.

The process of chromatin diminution in Parascaris and Ascaris is a developmentally controlled genome rearrangement, which results in quantitative and qualitative differences in DNA content between germ line and somatic cells. Chromatin diminution involves chromosomal breakage, new telomere formation and DNA degradation. The programmed elimination of chromatin in presomatic cells might serve as an alternative way of gene regulation. We put forward a new hypothesis of how an ancient partial genome duplication and chromatin diminution may have served to maintain the genetic balance in somatic cells and simultaneously endowed the germ line cells with a selective advantage.

A newly formed telomere in Ascaris suum does not exert a telomere position effect on a nearby gene.

During the process of chromatin diminution in Ascaris suum (formerly named Ascaris lumbricoides var. suum), developmentally regulated chromosomal fragmentation and new telomere addition occur within specific chromosomal breakage regions (CBRs). The DNA sequences flanking one of these CBRs (CBR-1) were analyzed, and two protein-encoding genes were found on either side. The noneliminated gene, agp-1, whose AUG start codon is located within approximately 2 kb of the boundary of CBR-1, encodes a putative GTP-binding protein which is structurally related to eukaryotic and prokaryotic elongation factors. Northern (RNA) blot analyses revealed that transcripts of this gene are present at all developmental stages, suggesting that the massive chromosomal rearrangements associated with the process of chromatin diminution have no influence on agp-1 expression. This demonstrates that addition of new telomeres in CBR-1 does not result in a telomeric position effect, a phenomenon previously described in Saccharomyces cerevisiae.

Variations in processes and structures of cardiac surgery practice.

It is hypothesized that variations in the processes and structures of the selection of patients and the conduct of the surgical procedure may influence risk-adjusted outcome in patients undergoing cardiac surgery. For this reason, the results of the pilot phase of this Veterans Affairs cooperative study were reviewed to determine the variation in the operative practices at six pilot institutions. There were large variations in the percentage of elective, urgent, and emergent cases at each institution, ranging from 58% to 96% elective, 3% to 31% urgent, and 1% to 8% emergent. There was also a tenfold increase in the preoperative use of intra-aortic balloon pump for control of unstable angina, varying from 0.8% to 10.6%. Five of the six centers had accredited thoracic surgical residency programs. There was large variation in the preoperative participation of attending surgeons, from 100% participation at three centers to less than 5% in one. The operation was performed by the attending surgeon in 28% of cases, but this varied from 0% to 100%, depending on the hospital. Cold cardioplegia was used almost uniformly (99%) for myocardial protection; the use of retrograde cardioplegia varied from 2% to 89% among hospitals, and the use of blood cardioplegia ranged from 0% to 100%, with an average of 54% of cases. The use of myocardial temperature monitoring varied between hospitals, from 25% to 99%. The use of the cell saving devices to scavenge shed blood varied from 5% to 99%, and the frequency of the use of banked blood varied from 25% to 65%, depending on the institution. The internal mammary artery was used for 67% patients undergoing coronary artery bypass graft, with a variation between hospitals of 39% to 83%. One hospital used a single cross-clamping technique for the performance of proximal anastomoses in 95% of cases, as opposed to all other hospitals, who used this technique in less than 10% of cases. Aortic venting varied from 58% to 98% and left ventricular venting from 1% to 38%. The use of porcine valves varied approximately 15% in three hospitals to 30% to 40% in the other three hospitals. There were tremendous variations in the duration of operative procedure (5.2-7.3 hours), actual operating time (4.0-5.6 hours), total cardiopulmonary bypass duration (102-146 minutes), and ischemic time (50-87 minutes). The use of inotropic support varied from 41% to 91% between hospitals.(ABSTRACT TRUNCATED AT 400 WORDS)

Evaluating anesthesia health care delivery for cardiac surgery. The role of process and structure variables.

Anesthesia care is an integral component of cardiac surgery. Emphasis on cost-effectiveness and decreased hospital stay has prompted reevaluation of anesthesia practice. However, the role of anesthesia process and structure variables in relation to patient outcomes is largely unknown. Processes, Structures and Outcomes of Care in Cardiac Surgery is the first epidemiologic study to collect data on anesthesia processes, such as the pharmacologic components of anesthesia and types of cardiovascular monitors used. Structures of care, such as resident staffing, supervision, completeness of documentation, and training and experience of care providers, are also being assessed. Pilot data collected from September 1992 to September 1993 demonstrate substantial variation between the six study sites in selected processes and structures. Despite the near-universal use of narcotic anesthesia as the primary anesthetic technique, variation in the type of opioid and adjuvant benzodiazepine used was observed. Regarding invasive hemodynamic monitoring, most centers used only one type of catheter. Intraoperative transesophageal echocardiography was used commonly at several centers for valve surgery, whereas other centers did not use it at all. Its use during coronary artery bypass grafting was less common. Assessment of the preoperative anesthesia note revealed that coronary anatomy and ventricular function were noted in nearly all instances. However, a clear notation that risks and benefits of anesthesia were discussed was less frequent. Structures related to anesthesia attending staffing, board certification, and experience revealed variation. Some sites had smaller and/or more experienced attending staffs, whereas others had larger and/or less experienced staffs. These pilot findings appear to validate the authors' hypotheses that variations in anesthesia practice are present within the Veterans Affairs system. They suggest that the variable set is robust enough to relate processes and structures of anesthesia care to patient outcome.

Tas, a retrotransposon from the parasitic nematode Ascaris lumbricoides.

The cloned retrotransposon Tas OE3 from the genome of the parasitic nematode Ascaris lumbricoides was completely sequenced. The element is flanked by long terminal repeats (LTR) and contains three distinct regions encoding putative proteins typical for retroid elements. The first region, ORF1, encodes a putative Gag protein including a 'Leu zipper', a nucleic acid binding motif, as well as an aspartic protease domain. The second region contains an incomplete ORF (ORF2) with sequence similarities to known retroviral reverse transcriptases (RT), ribonucleases H and integrases. A third ORF, which is located adjacent to the 3' LTR, might encode an env-like protein. Based on amino-acid sequence analysis of the RT domain, Tas falls into a new subgroup of LTR-containing retrotransposons.

Caenorhabditis elegans unc-51 gene required for axonal elongation encodes a novel serine/threonine kinase.

Mutations in the unc-51 gene of the nematode Caenorhabditis elegans result in various abnormalities in axonal elongation and axonal structures. We cloned the unc-51 gene by tagging with the transposon Tc1. The wild-type unc-51 gene, which rescued the mutant phenotypes, encodes a novel serine/threonine kinase of 856 amino acids. Mutation sites were identified in the unc-51 gene of six mutants. A Lys-->Met mutation created in vitro in the kinase domain led to the loss of rescuing activity and was dominant negative, indicating that the kinase domain of Unc-51 is essential for the function. Expression of an unc-51/lacZ fusion gene was observed in many neurons at all stages. We propose that protein phosphorylation by the unc-51 product is important for axonal elongation and possibly for axonal guidance.

Ribosomal heterogeneity from chromatin diminution in Ascaris lumbricoides.

The genome of Ascaris lumbricoides encodes both germline- and soma-specific proteins homologous to the eukaryotic small ribosomal protein (Rp) S19. The two Ascaris homologs differ by 24 amino acid substitutions and are both components of the small ribosomal subunits. In oocytes, the germline RpS19 homolog (RpS19G) predominates. During chromatin diminution, however, the gene is eliminated from all presomatic cells, and RpS19G is replaced by the product of the somatic gene (RpS19S). Chromatin diminution in A. lumbricoides causes a change in the protein composition of ribosomes during development and represents an alternative means of gene regulation.

Extremely stable transcripts may compensate for the elimination of the gene fert-1 from all Ascaris lumbricoides somatic cells.

The single-copy gene fert-1 becomes eliminated from all somatic cells during the process of chromatin diminution in Ascaris lumbricoides var. suum. By using Northern blot and in situ hybridization techniques, we have analyzed its rather unusual expression pattern. Different splicing and 3' end formation events generate in a developmentally regulated manner various poly(A)+ and poly(A)- fert-1 RNA species. The lack of any significant open reading frame in most of its RNA products indicates that fert-1 may function as structural RNA rather than encoding a protein. Fert-1 transcripts are produced in the precursors of the gametes, but degraded at the time of meiosis and not passed on to the zygote. Embryonic transcription of fert-1 sets in as soon as the female nucleus has completed its meiosis. Our data thus demonstrate that the Ascaris transcription apparatus is active prior to the general onset of zygotic transcription, which we think takes place in the four- to six-cell-stage embryos. Upon elimination of fert-1 gene from the somatic cells, most of its transcripts disappear. Two short fert-1 RNA products, however, are stably maintained throughout development until the second larval stage, which is more than 1 month after the elimination of their coding sequences. Possible functions of fert-1 are discussed.

Thromboembolism in patients undergoing thoracotomy.

To determine the incidence of thromboembolism in relation to thoracotomy, 77 patients undergoing pulmonary resection were prospectively studied up to 30 days postoperatively for deep venous thrombosis and pulmonary embolism. Overall, 20 of 77 patients (26%) had thromboembolic events during their hospitalization. Four deep venous thromboses and 1 pulmonary embolism were detected in 5 of 77 patients preoperatively for an incidence of 6%. Postoperative thromboembolism was detected in 15 of 77 (19%): deep venous thrombosis in 11 (14%) and pulmonary embolism in 4 (5%). No postoperative thromboembolisms occurred in the 17 patients receiving preoperative aspirin or ibuprofen, whereas they did occur in 25% of the remainder (15/60). Thromboembolism after pulmonary resection was more frequent with bronchogenic carcinoma than with metastatic cancer or benign disease (15/59 [25%] versus 0/18 [0%]; p < 0.01), adenocarcinoma compared with other types of carcinoma (11/25 [44%] versus 4/34 [12%]; p < 0.0004), large primary lung cancer (> 3 cm in diameter) compared with smaller lesions (9/19 [47%] versus 6/40 [15%]; p < 0.0001), stage II compared with stage I (7/14 [50%] versus 7/34 [21%]; p < 0.04), and pneumonectomy or lobectomy compared with segmentectomy and wedge resection (14/49 [29%] versus 1/28 [4%]; p < 0.005). Three of 4 patients with thromboembolism detected preoperatively had operation within the previous year. Postoperative pulmonary embolism was fatal in 1 of 4 (25%) and accounted for the one death. These results suggest patients undergoing thoracotomy for lung cancer, especially adenocarcinoma, should be considered for thromboembolic prophylaxis.

An update of solid organ transplantation at UAMS.

The one year survival for solid organ transplants is 70 to 90%. Encouraged by this success, the University of Arkansas for Medical Sciences is expanding its organ transplant center and will offer renal, pancreas, liver, heart, and lung within a year. The limiting factor in transplants continues to be a shortage of Donor organs and the need for increased referral of potential donors.