RESUMO
OBJECTIVES: To assess the use of epiaortic ultrasound in contemporary cardiac surgery, as well as its impact on surgical cannulation strategy and cerebrovascular events. DESIGN: Epiaortic ultrasound data was prospectively collected in the Randomized Endovein Graft Prospective (REGROUP) trial (VA Cooperative Studies Program #588, ClinicalTrials.gov, NCT01850082), which randomized 1,150 coronary artery bypass graft patients between 2014 and 2017 to endoscopic or open-vein graft harvest. SETTING: Sixteen cardiac surgery programs within the Veterans Affairs Healthcare System with expertise at performing endoscopic vein-graft harvesting. PARTICIPANTS: Veterans Affairs patients, greater than 18 years of age, undergoing elective or urgent coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest with at least one planned saphenous vein graft were eligible for enrollment. INTERVENTIONS: Epiaortic ultrasound was performed by the surgeon using a high frequency (>7 MHz) ultrasound transducer. Two-dimensional images of the ascending aorta in multiple planes were acquired before aortic cannulation and cross-clamping. MEASUREMENTS AND MAIN RESULTS: Epiaortic ultrasound was performed in 34.1% (269 of 790) of patients in REGROUP. Among these patients, simple intraluminal atheroma was observed in 21.9% (59 269), and complex intraluminal atheroma comprised 2.2% (6 of 269). The aortic cannulation or cross-clamp strategy was modified based on these findings in 7.1% of cases (19 of 269). There was no difference in stroke between patients who underwent epiaortic ultrasound and those who did not (1.9% v 1.2% pâ¯=â¯0.523). CONCLUSIONS: Despite current guidelines recommending routine use of epiaortic ultrasound (IIa/B) to reduce the risk of stroke in cardiac surgery, in this contemporary trial, use remains infrequent, with significant site-to-site variability.
Assuntos
Doenças da Aorta , Placa Aterosclerótica , Aorta , Ponte de Artéria Coronária , Humanos , Placa Aterosclerótica/diagnóstico por imagem , Estudos ProspectivosRESUMO
Cognitive workload data of members of the cardiac surgery team can be measured intraoperatively and stored for later analysis. We present a case of a near-miss (medication error) that underwent root cause analysis using workload data. Heart rate variability data, representing workload levels, were collected from the attending surgeon, attending anesthesiologist, and lead perfusionist using wireless heart rate monitors. An episode of cognitive overload of the anesthesiologist due to a distractor was associated with the preventable error. Additional studies are needed to better understand the role of psychophysiological data in enhancing surgical patient safety.
Assuntos
Anestesistas/psicologia , Cognição , Ponte de Artéria Coronária/efeitos adversos , Erros de Medicação/prevenção & controle , Near Miss , Equipe de Assistência ao Paciente , Carga de Trabalho , Administração Intravenosa , Competência Clínica , Frequência Cardíaca , Antagonistas de Heparina/administração & dosagem , Antagonistas de Heparina/efeitos adversos , Humanos , Protaminas/administração & dosagem , Protaminas/efeitos adversos , Medição de Risco , Fatores de Risco , Análise de Causa FundamentalRESUMO
Through bound apolipoprotein A-I (apoA-I), high-density lipoprotein cholesterol (HDL-C) activates endothelial nitric oxide synthase, inducing vasodilation. Because patients with sickle cell disease (SCD) have low apoA-I and endothelial dysfunction, we conducted a randomized, double-blinded, placebo-controlled trial to test whether extended-release niacin (niacin-ER) increases apoA-I-containing HDL-C and improves vascular function in SCD. Twenty-seven patients with SCD with levels of HDL-C <39 mg/dl or apoA-I <99 mg/dl were randomized to 12 weeks of niacin-ER, increased in 500-mg increments to a maximum of 1,500 mg/day, or placebo. The primary outcome was the absolute change in HDL-C level after 12 weeks, with endothelial function assessed before and at the end of treatment. Niacin-ER-treated patients trended to greater increase in HDL-C level compared with placebo treatment at 12 weeks (5.1 ± 7.7 vs 0.9 ± 3.8 mg/dl, 1-tailed p = 0.07), associated with significantly greater improvements in the ratios of low-density lipoprotein to HDL-C levels (1.24 vs 1.95, p = 0.003) and apolipoprotein B to apoA-I levels (0.46 vs 0.58, p = 0.03) compared with placebo-treated patients. No improvements were detected in 3 independent vascular physiology assays of endothelial function. Thus, the relatively small changes in HDL-C levels achieved by the dose of niacin-ER used in our study are not associated with improved vascular function in patients with SCD with initially low levels of apoA-I or HDL-C.
Assuntos
Anemia Falciforme/tratamento farmacológico , HDL-Colesterol/sangue , Endotélio Vascular/fisiopatologia , Lipídeos/sangue , Niacina/administração & dosagem , Vasodilatação/efeitos dos fármacos , Adolescente , Adulto , Idoso , Anemia Falciforme/sangue , Anemia Falciforme/fisiopatologia , HDL-Colesterol/efeitos dos fármacos , Preparações de Ação Retardada , Relação Dose-Resposta a Droga , Método Duplo-Cego , Endotélio Vascular/efeitos dos fármacos , Feminino , Seguimentos , Humanos , Hipolipemiantes/administração & dosagem , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Vascular dysfunction is an important pathophysiologic manifestation of sickle cell disease (SCD), a condition that increases risk of pulmonary hypertension and stroke. We hypothesized that infrared (IR) imaging would detect changes in cutaneous bloodflow reflective of vascular function. We performed IR imaging and conventional strain gauge plethysmography in twenty-five adults with SCD at baseline and during intra-arterial infusions of an endothelium-dependent vasodilator acetylcholine (ACh), an endothelium-independent vasodilator sodium nitroprusside (SNP), and a NOS inhibitor L-NMMA. Skin temperature measured by IR imaging increased in a dose-dependent manner to graded infusions of ACh (+1.1°C, p<0.0001) and SNP (+0.9°C, p<0.0001), and correlated with dose-dependent increases in forearm blood flow (ACh: +19.9 mL/min/100 mL, p<0.0001; r(s)=0.57, p=0.003; SNP: +8.6 mL/min/100 mL, p<0.0001; r=0.70, p=0.0002). Although IR measurement of skin temperature accurately reflected agonist-induced increases in blood flow, it was less sensitive to decreases in blood flow caused by NOS inhibition. Baseline forearm skin temperature measured by IR imaging correlated significantly with baseline forearm blood flow (31.8±0.2°C, 6.0±0.4 mL/min/100 mL; r=0.58, p=0.003), and appeared to represent a novel biomarker of vascular function. It predicted a blunted blood flow response to SNP (r=-0.61, p=0.002), and was independently associated with a marker of pulmonary artery pressure, as well as hemoglobin level, diastolic blood pressure, homocysteine, and cholesterol (R(2)=0.84, p<0.0001 for the model). IR imaging of agonist-stimulated cutaneous blood flow represents a less cumbersome alternative to plethysmography methodology. Measurement of baseline skin temperature by IR imaging may be a useful new marker of vascular risk in adults with SCD.
Assuntos
Anemia Falciforme/sangue , Anemia Falciforme/patologia , Óxido Nítrico/metabolismo , Espectrofotometria Infravermelho/métodos , Acetilcolina/metabolismo , Adulto , Velocidade do Fluxo Sanguíneo , Relação Dose-Resposta a Droga , Ecocardiografia/métodos , Endotélio Vascular/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Óxido Nítrico Sintase/metabolismo , Análise de Regressão , Risco , Temperatura Cutânea , ômega-N-Metilarginina/farmacologiaRESUMO
George Emil Palade's scientific contributions significantly advanced the field of modern cell biology. He pioneered a multidisciplinary approach, combining cell fractionation, biochemistry, and electron microscopy, which led to the identification of the ribosome as the site of protein synthesis and elucidated the eukaryotic secretory pathway. For these accomplishments, Palade, along with Albert Claude and Christian de Duve, won the 1974 Nobel Prize in Physiology or Medicine. This article provides an overview of Palade's seminal research in the context of the early developments in the field.
Assuntos
Biologia Celular/história , Bioquímica/história , Fracionamento Celular , História do Século XX , História do Século XXI , Microscopia Eletrônica , Prêmio Nobel , Biossíntese de Proteínas , RibossomosRESUMO
Pulmonary hypertension (PH) in sickle cell disease (SCD) is an emerging and important clinical problem. In a single-institution adult cohort of 365 patients, we investigated lipid and lipoprotein levels and their relationship to markers of intravascular haemolysis, vascular dysfunction and PH. In agreement with prior studies, we confirm significantly decreased plasma levels of total cholesterol, high-density lipoprotein-cholesterol (HDL-C) and low-density lipoprotein-cholesterol (LDL-C) in SCD versus ethnically-matched healthy controls. Several cholesterol parameters correlated significantly with markers of anaemia, but not endothelial activation or PH. More importantly, serum triglyceride levels were significantly elevated in SCD compared to controls. Elevated triglyceride levels correlated significantly with markers of haemolysis (lactate dehydrogenase and arginase; both P < 0.0005), endothelial activation (soluble E-selectin, P < 0.0001; soluble P-selectin, P = 0.02; soluble vascular cell adhesion molecule-1, P = 0.01), inflammation (leucocyte count, P = 0.0004; erythrocyte sedimentation rate, P = 0.02) and PH (amino-terminal brain natriuretic peptide, P = 0.002; prevalence of elevated tricuspid regurgitant velocity (TRV), P < 0.001). In a multivariate analysis, triglyceride levels correlated independently with elevated TRV (P = 0.002). Finally, forearm blood flow studies in adult patients with SCD demonstrated a significant association between increased triglyceride/HDL-C ratio and endothelial dysfunction (P < 0.05). These results characterize elevated plasma triglyceride levels as a potential risk factor for PH in SCD.
Assuntos
Anemia Falciforme/sangue , Anemia Falciforme/complicações , Hipertensão Pulmonar/etiologia , Lipídeos/sangue , Adulto , Anemia Falciforme/fisiopatologia , Biomarcadores/sangue , Estudos de Casos e Controles , Colesterol/sangue , HDL-Colesterol/sangue , Endotélio Vascular/fisiopatologia , Feminino , Hemólise , Humanos , Hipertensão Pulmonar/sangue , Lipoproteínas/sangue , Masculino , Pessoa de Meia-Idade , Triglicerídeos/sangueRESUMO
Emtricitabine [(-)FTC; (-)-beta-L-2'-3'-dideoxy-5-fluoro-3'-thiacytidine] is an oxathiolane nucleoside analog recently approved by the Food and Drug Administration for the treatment of human immunodeficiency virus (HIV). Structurally, (-)FTC closely resembles lamivudine [(-)3TC] except that the former is 5-fluorinated on the cytosine ring. In HIV-1 reverse transcriptase (RT) enzymatic assays, the triphosphate of (-)FTC [(-)FTC-TP] was incorporated into both DNA-DNA and DNA-RNA primer-templates nearly 3- and 10-fold more efficiently than (-)3TC-TP. Animal studies and clinical trial studies have demonstrated a favorable safety profile for (-)FTC. However, a detailed study of the incorporation of (-)FTC-TP by human mitochondrial DNA polymerase gamma, a host enzyme associated with nucleoside toxicity, is required for complete understanding of the molecular mechanisms of inhibition and toxicity. We studied the incorporation of (-)FTC-TP and its enantiomer (+)FTC-TP into a DNA-DNA primer-template by recombinant human mitochondrial DNA polymerase in a pre-steady-state kinetic analysis. (-)FTC-TP was incorporated 2.9 x 10(5)-, 1.1 x 10(5)-, 1.6 x 10(3)-, 7.9 x 10(3)-, and 100-fold less efficiently than dCTP, ddCTP, (+)3TC-TP, (+)FTC-TP, and (-)3TC-TP, respectively. The rate of removal of (-)FTC-MP from the corresponding chain-terminated 24-mer DNA by polymerase gamma's 3'-->5' exonuclease activity was equal to the removal of (+)FTC-MP, 2-fold slower than the removal of (-)3TC-MP and (+)3TC-MP, and 4.6-fold slower than the excision of dCMP. These results demonstrate that there are clear differences between HIV-1 RT and polymerase gamma in terms of preferences for substrate structure.
Assuntos
Antivirais/farmacologia , Antivirais/toxicidade , DNA Polimerase Dirigida por DNA/metabolismo , Nucleotídeos de Desoxicitosina/farmacologia , Nucleotídeos de Desoxicitosina/toxicidade , Transcriptase Reversa do HIV/metabolismo , Mitocôndrias/enzimologia , Inibidores da Transcriptase Reversa/farmacologia , Inibidores da Transcriptase Reversa/toxicidade , DNA/metabolismo , DNA Polimerase gama , Didesoxinucleotídeos , Transcriptase Reversa do HIV/isolamento & purificação , Humanos , Isoenzimas/isolamento & purificação , Isoenzimas/metabolismo , Cinética , Estereoisomerismo , Relação Estrutura-Atividade , Especificidade por SubstratoRESUMO
Beta-D and beta-L-enantiomers of 2',3'-dideoxycytidine analogues are potent chain-terminators and antimetabolites for viral and cellular replication. Seemingly small modifications markedly alter their antiviral and toxicity patterns. This review discusses previously published and recently obtained data on the effects of 5- and 2'-fluorine substitution on the pre-steady state incorporation of 2'-deoxycytidine-5'-monophosphate analogues by HIV-1 reverse transcriptase (RT) in light of their biological activity. The addition of fluorine at the 5-position of the pyrimidine ring altered the kinetic parameters for all nucleotides tested. Only the 5-fluorine substitution of the clinically relevant nucleosides (-)-beta-L-2',3'-dideoxy-3'-thia-5-fluorocytidine (L-FTC, Emtriva), and (+)-beta-D-2',3'-didehydro-2',3'-dideoxy-5-fluorocytidine (D-D4FC, Reverset), caused a higher overall efficiency of nucleotide incorporation during both DNA- and RNA-directed synthesis. Enhanced incorporation by RT may in part explain the potency of these nucleosides against HIV-1. In other cases, a lack of correlation between RT incorporation in enzymatic assays and antiviral activity in cell culture illustrates the importance of other cellular factors in defining antiviral potency. The substitution of fluorine at the 2' position of the deoxyribose ring negatively affects incorporation by RT indicating the steric gate of RT can detect electrostatic perturbations. Intriguing results pertaining to drug resistance have led to a better understanding of HIV-1 RT resistance mechanisms. These insights serve as a basis for understanding the mechanism of action for nucleoside analogues and, coupled with studies on other key enzymes, may lead to the more effective use of fluorine to enhance the potency and selectivity of antiviral agents.