Characteristics of Modified Leghemoglobins Isolated from Soybean (Glycine max Merr.) Root Nodules.

Hemoprotein derivatives of an abundant soybean (Glycine max Merr.) root nodule leghemoglobin, Lba, were studied for their modified spectral characteristics and physical properties. Three modified hemoprotein derivatives of Lba (Lbam1, Lbam2, and Lbam3) were purified by preparative isoelectric focusing. The ferric forms of these pigments were green and exhibited anomalous spectra in the visible region as compared to the Lba3+ forms. These modified pigments showed a hypochromic shift of 10 nm for the charge transfer absorption maximum; however, differences were not apparent in the Soret region. Upon binding with nicotinate, the [alpha] and [beta] bands were shifted significantly into the red region as compared to the Lba3+ nicotinate complex. The three Lbam fractions were reduced by dithionite or by NADH in the presence of riboflavin. Lbam2+ also bound nicotinate and displayed absorption spectra indistinguishable from those of Lba2+ nicotinate. In contrast to Lba2+, Lbam2+ displayed aberrant spectra when bound with either O2 or CO. These complexes exhibited a prominent charge transfer band at approximately 620 nm and failed to exhibit spectra characteristic of Lba2+O2 and Lba2+CO. The protein moiety of these modified pigments was intact because their tyrosine/tryptophan ratios and their amino acid compositions were identical with those of Lba, nor were differences observed in the peptide profiles resulting from trypsin digests of purified Lba and Lbams. Automated Edman degradation of selected peaks further confirmed the intactness of the protein backbone including the absence of deamination. Pyridine hemochromogen for heme from Lbams could be formed, and the spectra displayed distinct differences compared to those of Lba. A new peak at 580 nm and a loss of a peak at 480 nm were observed for all three Lbams.

N2 Fixation, Carbon Metabolism, and Oxidative Damage in Nodules of Dark-Stressed Common Bean Plants.

Common beans (Phaseolus vulgaris L.) were exposed to continuous darkness to induce nodule senescence, and several nodule parameters were investigated to identify factors that may be involved in the initial loss of N2 fixation. After only 1 d of darkness, total root respiration decreased by 76% and in vivo nitrogenase (N2ase) activity decreased by 95%. This decline coincided with the almost complete depletion (97%) of sucrose and fructose in nodules. At this stage, the O2 concentration in the infected zone increased to 1%, which may be sufficient to inactivate N2ase; however, key enzymes of carbon and nitrogen metabolism were still active. After 2 d of dark stress there was a significant decrease in the level of N2ase proteins and in the activities of enzymes involved in carbon and nitrogen assimilation. However, the general collapse of nodule metabolism occurred only after 4 d of stress, with a large decline in leghemoglobin and antioxidants. At this final senescent stage, there was an accumulation of oxidatively modified proteins. This oxidative stress may have originated from the decrease in antioxidant defenses and from the Fe-catalyzed generation of activated oxygen due to the increased availability of catalytic Fe and O2 in the infected region.

Osteomyelitis of the clavicle after Swan-Ganz catheterization.

Osteomyelitis of the clavicle is an uncommon complication of Swan-Ganz catheterization. The diagnosis should be suspected when the clinical features of fever and sterno-clavicular pain are present. Traditional roentgenograms may be falsely normal early in the disease. Radioactive isotope scanning may be helpful in establishing the diagnosis sooner, followed by tomography or computed tomography to better define the abnormality. Therapy should include long-term parenteral antibiotics and possible surgical removal.

Complexes of iron with phenolic compounds from soybean nodules and other legume tissues: prooxidant and antioxidant properties.

The low-molecular-mass fraction of the soybean nodule cytosol contains Fe capable of catalyzing free radical production through Fenton chemistry. A large portion of the pool of catalytic Fe, measured as bleomycin-detectable Fe, was characterized as complexes of Fe with phenolic compounds of three classes: phenolic acids, cinnamic acids, and flavonoids. Many of these compounds, along with other phenolics present in legume tissues, were used for a systematic structure-activity relationship study. All phenolics tested were able to chelate Fe, as judged from their inhibitory effect on site-specific deoxyribose degradation (minus EDTA assay). However, only those having catechol, pyrogallol, or 3-hydroxy-4-carbonyl groupings were potent chelators and reductants of Fe3+ at pH 5.5. The same phenolics promoted oxidative damage to DNA (bleomycin assay) and to deoxyribose (plus EDTA assay), but inhibited linolenic acid peroxidation by chelating and reducing Fe3+ and by neutralizing lipid radicals. Also, phenolics having a pyrogallol nucleus attenuated the free radical-mediated inactivation of glutamine synthetase, which was used as a model system, by chelating Fe2+. It is reasoned that under the microaerobic (10-20 nM O2) and acidic (pH 5.5-6.4) conditions prevailing in nodules, phenolics are likely to act primarily as antioxidants, decreasing oxidative damage to biomolecules.

Failure of early heparin cessation as treatment for heparin-induced thrombocytopenia.

PURPOSE: The complications of heparin-induced thrombocytopenia include thrombosis and death. The purpose of the study was to determine whether early heparin cessation can prevent these outcomes. SUBJECTS AND METHODS: We performed a retrospective analysis of consecutive patients with heparin-induced thrombocytopenia diagnosed by platelet aggregometry. Demographic, clinical, and laboratory findings were compared in patients by whether heparin treatment was stopped early (< or = 48 hours) or late (>48 hours) after the onset of thrombocytopenia, as well as between patients with and without thrombosis. Thrombocytopenia was defined as a 50% decline in baseline platelet counts or an absolute platelet count < 100,000/mm3. RESULTS: Of the 113 patients, 38% developed thrombosis and 27% died. One-half of patients had thrombosis diagnosed >24 hours after heparin cessation. No difference in thrombosis or mortality was found in the 40 patients with early heparin cessation [mean (+/-SD) time of cessation 0.7 +/- 0.6 days] compared with the 73 patients with late heparin cessation (5 +/- 3 days). Thrombosis >24 hours after heparin cessation occurred in 61% of the patients in the early group and in 40% of the late group (P = 0.17). In a multivariate analysis, only a lower nadir of the platelet count (percent of baseline) was associated with thrombosis. Neither thrombosis nor the time to heparin cessation were associated with mortality. CONCLUSIONS: Early heparin cessation was not effective in reducing morbid events in patients with heparin-induced thrombocytopenia. Treatment strategies other than heparin cessation alone should be considered in patients with this condition.

Pulmonary mucinous cystic tumor. Case report with review of the literature.

Mucinous cystic tumors of the lung are exceedingly rare. We describe the case of a 59-year-old white man with a left upper lobe mass documented on chest radiographs 11 years before thoracotomy. Grossly, the lobectomy specimen contained a 4.5 x 4.5 x 4.0 cm cystic gelatinous mass with complete occlusion of the anterior segmental bronchus by mucinous material. Although microscopically this pulmonary mucinous cystic tumor contained a focus of marked glandular atypia consistent with adenocarcinoma, the patient has remained free of recurrence or metastasis during 5 years of close postoperative follow-up. Pulmonary mucinous cystic tumors appear to have a remarkably favorable prognosis and should be distinguished from other common lung neoplasms.

Regulation by chronic drug administration of neuronal and cardiac calcium channel, beta-adrenoceptor and muscarinic receptor levels.

Chronic administration of atropine (40-100 mg/kg, 23 days) produced a 29-33% increase in muscarinic receptors, measured by [3H]quinuclidinyl benzilate binding, in rat brain. Diisopropyl phosphorofluoridate (0.9 mg/kg, 14 days) produced a 35% decrease in muscarinic receptors. Propranolol administration (800 micrograms/kg/hr, 10 days) increased beta-adrenoceptors, measured by [3H]dihydroalprenolol binding, by 69 and 50% in brain and heart respectively. Isoproterenol administration (800 micrograms/kg/hr, 10 days) produced a 50% reduction in cardiac beta-adrenoceptors but did not alter brain receptors. These drug treatments were without effect on binding of the Ca2+ channel ligands, [3H]nimodipine and [3H]nitrendipine, to brain or heart respectively. However, chronic administration of nifedipine for 20 days (36 and 360 micrograms/kg/hr) did produce down-regulation of both cardiac and neuronal Ca2+ channels and a similar down-regulation of beta-adrenoceptors. Co-regulation of Ca2+ channels and neurotransmitter receptors may occur but may not be an automatic consequence of either receptor or channel regulation.

Regional pulmonary function during experimental unilateral pneumothorax in the awake state.

This study examines changes in regional pulmonary function during unilateral pneumothorax, immediately after, and 2 hours following re-expansion in awake dogs. Respiratory rate, tidal volume, physiologic dead space, arterial blood gases, and pulmonary shunt fraction were determined at each stage. Cardiac output (thermodilution), vascular pressures, and regional ventilation and perfusion (133Xe scans) were also measured. Chest roentgenogram confirmed the presence of UP. Respiratory rate increased 124 percent (p less than 0.01) during UP while alveolar ventilation remained unchanged. Pulmonary shunt fraction rose 93 percent (p less than 0.01) during UP, causing PaO2 to fall from 86 to 51 mm. Hg (p less than 0.01). PaCO2, pH, and cardiac output were not altered by UP. UP caused a relative underventilation of the collapsed lung (V/Q = 0.73 (p less than 0.01)) and an overventilation of the contralateral lung (V/Q = 1.74) (p less than 0.01). Immediately after re-expansion of the collapsed lung, all the above changes reverted to the control values. All variables remained unchanged 2 hours following complete re-expansion.

Electrocardiographic J waves after resuscitation from cardiac arrest.

A patient was monitored prior to, during, and after cardiac arrest with a Holter monitor and an electrocardiograph. The arrest occurred without any premonitory signs on the ECG. At the onset of the arrest, torsades de pointes ventricular tachycardia occurred, which quickly degenerated into ventricular fibrillation. After a successful second defibrillation, the patient developed Osborn waves, which subsided within a few minutes.

The effect of positive end-expiratory pressure on regional ventilation and perfusion in the normal and injured primate lung.

Although positive end-expiratory pressure (PEEP) is being employed in the management of respiratory insufficiency, many of its physiological effects remain undetermined. The cardiopulmonary effects of PEEP as well as its effect on regional ventilation and perfusion were studied in 10 baboons before and after pulmonary injury with oleic acid. In the normal lung, there was significant improvement in oxygenation at a PEEP of 5 cm. of water secondary to improved ventilation and perfusion in all PEEP greater than 5 cm. of water produced increasing mismatch of ventilation and perfusion in all zones. After oleic acid was injected, hypoxemia was evident with a reversal of the normal ventilation-perfusion (V/Q) relationship between upper and lower lung zones. This mismatch of ventilation and perfusion was corrected at a PEEP of 15 cm. of water. It was reasonable to conclude that the use of PEEP in the injured lung exerts it beneficial effect by balancing regional ventilation and perfusion in addition to increasing functional residual capacity.

Video-assisted minimally invasive mitral valve surgery.

OBJECTIVE: This study was done to determine the potential benefits of minimally invasive mitral surgery performed with intraoperative video assistance. METHODS: From May 1996 until March 1997, a minithoracotomy and video assistance were used in 31 consecutive patients undergoing mitral repair (n = 20) and replacement (n = 11). Their ages ranged from 18 to 77 years (59 +/- 2.6 years; mean +/- standard error of the mean). Ejection fractions were 35% to 62% (55% +/- 1.5%). Operations were done with either antegrade/retrograde (n = 10) or antegrade (n = 19) cold blood cardioplegia and a new transthoracic crossclamp or with ventricular fibrillation (n = 2). Peripheral arterial cannulation (n = 28) and pump-assisted right atrial drainage (n = 26) were used most often. RESULTS: No hospital deaths occurred, but the 30-day mortality was 3.2%. Complications included deep venous thrombosis and a phrenic nerve palsy in one patient each. No patient had a stroke or required reoperation for bleeding. Postoperative echocardiography showed excellent valve function in all but one patient. Cardiopulmonary bypass and arrest times averaged 183 +/- 7.2 and 136 +/- 5.5 minutes, respectively. Compared with 100 patients having conventional mitral valve operations, these patients had significantly shorter hospitalization times (8.6 +/- 0.5 vs 5.1 +/- 0.9 days, p = 0.05). Moreover, 81% of the later cohort were discharged between day 3 and 5 (3.6 +/- 0.2 days). Hospital charges (decreases 27%, p = 0.05) and costs (decreases 34%, p < 0.05) were less than in conventional operations. Patient follow-up suggested minimal perioperative pain and rapid recovery. CONCLUSIONS: Early results suggest that video-assisted minimally invasive mitral operations can be done safely. These methods may benefit patients through less morbidity, earlier discharge, and lower cost.

Refractory ventricular arrhythmia: the role of intraoperative electrophysiological study.

Thirty patients with drug refractory ventricular tachycardia (RVT) were studied between 1 week and 5 years after myocardial infarction with coronary agniography and left ventriculography. They were divided into four groups: (1) inoperable, five patients; (2, a) operated, with primary left ventricular failure, five patients; (2, b) operated with primary RVT, not mapped, 15 patients; (2, c) operated, with mapping, five patients. The mortality rate in group 1 was 100%, and in group 2, a it was 80%. In group 2, b, despite aggressive drug therapy and operation, including aneurysmectomy, coronary revascularization, and intra-aortic balloon pumping when appropriate, the mortality rate wad intraoperative mapping in group 2, c. Arrhythmogenic foci were identified and removed in four. There was one operative death (20%) and four patients are alive from 12 to 27 months after operation, three of whom are asymptomatic. Intraoperative epicardial mapping is an important adjunct to surgery for RVT.

Neonatal aortic thrombosis complicating umbilical artery catheterization: successful treatment with retroperitoneal aortic thrombectomy.

A newborn infant with a history of umbilical artery catheterization had renal vascular hypertension and congestive heart failure. An abdominal ultrasound examination revealed aortic thrombosis extending from the celiac axis to the aortic bifurcation. Retroperitoneal aortic thrombectomy was performed without difficulty. The infant's hypertension and cardiac failure resolved. The retroperitoneal approach allowed excellent exposure of the aorta and avoided the postoperative gastrointestinal morbidity associated with a transperitoneal approach.

Effects of oxygen toxicity on regional ventilation and perfusion in the primate lung.

Since the effect of prolonged exposure to high concentrations of oxygen on regional ventilation and perfusion has not been previously, a reproducible primate model of oxygen toxicity was developed to investigate the pathophysiologic changes that occur. Regional ventilation and perfusion were measured by 133Xe techniques in 10 baboons before and after 108 hours of continuous exposure to an inspired oxygen concentration of more than 90%. Arterial blood gases, shunt fraction (QS/QT), cardiac output, physiologic dead space (VD/VT), and pulmonary vascular resistance were also measured. Light and electron microscopic histology confirmed early pathologic changes of oxygen toxicity in every animal after exposure. PaO2 in room air decreased markedly after exposure from 90 +/- 4 to 46 +/- 5 mm Hg, and QS/QT rose to 30 +/- 2%. VD/VT, PaCO2, and pH were not altered by exposure to hyperoxia. Similarly, cardiac output and pulmonary vascular resistance remained unchanged. The distribution of regional ventilation and perfusion remained normal during and after prolonged high-oxygen exposure. Early oxygen toxicity was characterized by profound hypoxemia without regional ventilation-perfusion mismatch. Although impaired diffusion through a thickened alveolar membrane may be partially responsible for this hypoxemia, the markedly increased alveolar-arterial oxygen gradient when FIO2 = 1.0 indicates that shunting at the alveolar level (secondary to absorptive collapse or pulmonary edema) is a major cause of the hypoxemia.

Risks and benefits of the treatment of heart failure. Current status.

Congestive heart failure is an increasingly common patient problem. It is a multisystem disease that involves not only the heart but also the kidneys and neurohormonal systems. Any treatment for heart failure should address depressed contractility and exercise intolerance, as well as control compensatory mechanisms. There are many different approaches to the treatment of congestive heart failure: among the drugs used are diuretics, digitalis compounds, nitrates, calcium channel blockers, beta-blockers, beta-agonists, vasodilators, angiotensin-converting enzyme (ACE) inhibitors and the new phosphodiesterase inhibitors. The therapy usually involves a multiple drug treatment plan to achieve the maximum effect for the patient with the lowest incidence of side effects. Heart failure involves a large spectrum of patients with left ventricular dysfunction, and success at achieving treatment goals with these patients will vary with the severity of that symptom. A major concern is that increasing contractility may further damage the myocardium and shorten the survival of these patients, although there is as yet no evidence of such shortening. The new phosphodiesterase inhibitor drugs are an exciting development in the treatment of heart failure, because they add a dimension to the treatment for patients who are not sufficiently improved by a regimen of digoxin, diuretics and ACE inhibitors. Any new heart failure medication should be able to improve rest and exercise haemodynamics, maintain its benefits when given orally and result in an improved exercise capacity and quality of life, and prolonged survival.

Long term survival of class IV heart failure patients treated with oral amrinone.

The purpose of this study was to evaluate the effect of amrinone on the survival of a group of 51 Class IV congestive heart failure patients as well as changes in exercise capacity, hemodynamics, and clinical status. In those 22 patients able to exercise before treatment with amrinone, exercise duration increased from 4.15 minutes to 6.58 minutes on the treadmill. In those 19 patients first treated with intravenous amrinone, there was an increase in cardiac index from 1.9 to 2.6 L/min/m2. Thirty seven patients (72%) died in the follow-up period, most in the first four months. In this group of Class IV heart failure patients, there were two subsets of patients: one with a stable course (Group I) and one with a malignant course (Group II). The Group II patients accounted for much of the mortality in the follow-up. Patients with coronary artery disease did worse than patients with idiopathic dilated cardiomyopathies. There was no evidence that amrinone shortened or prolonged the survival of these Class IV patients.

Minimally invasive mitral valve repair using transthoracic aortic occlusion.

This report describes a minimally invasive mitral valve repair done through a limited (6-cm) thoracic incision. The patient was supported by peripheral extracorporeal perfusion with cardiac arrest established using a new transthoracic aortic cross-clamp and antegrade blood cardioplegia. The patient was discharged on postoperative day 3 with minimal pain. This less invasive approach to mitral valve surgery may offer combined advantages to patients by increasing comfort, expediting recovery, and decreasing surgical costs by using modified traditional methods compared with specialized intraaortic occlusive balloons.

Infective aortic endocarditis after percutaneous balloon aortic valvuloplasty.

Infective aortic endocarditis developed in an elderly patient after a percutaneous balloon aortic valvuloplasty. The transesophageal echocardiogram demonstrated a perivalvular abscess. The patient underwent surgical replacement of the infected valve, but later succumbed to renal failure. The development of infective aortic endocarditis should be recognized as a potentially fatal complication of percutaneous balloon aortic valvuloplasty. The important measures in preventing bacteremia during percutaneous balloon aortic valvuloplasty and the appropriate role of operation are discussed.

Long-term results of pulmonary resection for atypical mycobacterial disease.

From 1967 through 1981, 40 pulmonary resections were performed in 37 patients with Mycobacterium intracellulare infection. The patients ranged in age from 24 to 67 years, and 86% were men. Smoking and alcohol abuse seemed to be predisposing factors. Localized atypical mycobacterial infection unresponsive to chemotherapy was the operative indication for 38 of the 40 resections. All patients had cavitary disease. Mean length of preoperative drug treatment was 22 weeks. Sensitivity studies showed a very high incidence of in vitro drug resistance. Twenty-five patients were converted to sputum-negative status preoperatively; however, 23 of these had positive smears or cultures from their resected specimens. Resections performed included upper lobectomy in 31 patients, upper and middle lobectomy in 2 patients, upper lobectomy plus superior segmentectomy in 3, left completion pneumonectomy in 2, and wedge resection in 2. Two patients underwent staged bilateral upper lobectomies. There were no perioperative deaths. Complete follow-up in 33 patients (mean, 94 months) revealed only two reactivations at 3 and 5 years postoperatively. One of these patients is well following completion pneumonectomy 9 years after his first operation; the second patient responded to reinstitution of three-drug chemotherapy and is well 5 years later. Thirty-one patients have remained entirely free of disease. Excisional surgery remains the treatment of choice for localized M. intracellulare pulmonary infection.

Myocardial revascularization in the elderly using beating heart coronary artery bypass surgery.

BACKGROUND: Beating heart or "off-pump" coronary artery bypass (OP-CAB) has become an accepted method of myocardial revascularization by reducing the perioperative morbidity related to cardiopulmonary bypass (CPB). However, the efficacy of OP-CAB has not been well established in the elderly patient population. METHODS: OP-CABs were performed in 53 patients aged 75 years and older, at Pitt County Memorial Hospital from January 1996 to October 1999, either through a median sternotomy or an anterior thoracotomy. These results were compared with 220 patients who underwent standard coronary artery bypass graft (CABG) operation using CPB during the same time period. RESULTS: Mean patient age for both groups was 79+/-0.5 years and preoperative risk factors were similar. There were no differences in postoperative myocardial infarction, atrial fibrillation, bleeding, neurologic complications, or renal failure. There were no deaths after OP-CAB, compared with the 7.6% operative mortality rate after CABG (p<0.05). The OP-CAB group had a significantly shorter postoperative length of stay (4.4+/-0.4 days vs. 8.4+/-0.6 days) and lower transfusion requirements (0.4+/-0.1 units packed red blood cells vs 1.9+/-0.2 units packed red blood cells) than the CABG group. CONCLUSIONS: Our data demonstrate that OP-CAB is a safe and efficacious method of myocardial revascularization in the elderly, and may actually be preferential in these patients when applicable.