Percutaneous endovascular treatment of innominate artery lesions: a single-centre experience on 77 lesions.

PURPOSE: To assess primary success and safety of percutaneous transluminal angioplasty and/or stenting of innominate artery lesions and to compare its 30-day stroke/mortality level with the literature data. METHODS: A total of 72 patients (77 stenoses, five recurrent, 58 symptomatic and 39 female) with seven innominate vessel occlusions, nine subocclusive lesions and 61 significant (>60%) stenoses of innominate artery treated between 2000 and 2009 were retrospectively reviewed. With the exception of seven, all procedures were performed using a transfemoral approach. A stent was implanted in 49 (63.6%) cases. Follow-up included neurological examination, carotid duplex scan and office/telephone interview. RESULTS: Primary technical success was 93.5% (72/77). There was neither periprocedural (<48 h) death, nor major neurological complication. Minor periprocedural neurological complications consisted of 2/72 (2.6%) ipsilateral TIAs. Access site complications included 4 (5.2%) access site bleedings. Follow-up was achieved in 65/72 (90.3%) of all patients and 68 (88.3%) of all procedures for a mean of 42.3 months and revealed neither major neurological complication, nor additional TIA. The cumulative primary patency rate was 100% at 12 months, 98+/-1.6% at 24 months, and 69.9+/-8.5% at 96 months. The cumulative secondary patency rate was 100% at 12 and at 24 months, and 81.5+/-7.7% at 96 months. Log-rank test showed no significant difference (p=0.79) in primary cumulative patencies between PTA alone (n=28) or PTA/stent (n=49). CONCLUSION: Transfemoral PTA with or without stent appears to be a safe treatment option for innominate artery lesions.

Cytotoxic effects of erythromycin estolate and chlorpromazine on hepatocytes isolated from rats of varying ages: a brief note.

Hepatocytes isolated from young (1 month) rats were as sensitive to the cytotoxic effects of erythromycin estolate and chlorpromazine as were liver cells obtained from older (3, 10 and 24 months) rats. The hepatocytes from the 24-month-old rats released aspartate transaminase more slowly than did parenchymal cells isolated from the younger rats.

Study of DNA metabolism of lymph-node cells by direct lymphatic administration of tritiated thymidine.

A method for studying DNA metabolism in lymph-node cells by injecting tritiated thymidine intralymphatically is described. The administration of [3H]thymidine through a lymph vessel enabled a high concentration to be attained with only a small quantity of the precursor in close proximity to the cells. The significance of the method is that it may also be used in studies of metabolic processes in human lymph-nodes.

Haemophilus influenzae type b conjugate vaccine (meningococcal protein conjugate) (PedvaxHIB): clinical evaluation.

Although systemic infections caused by Haemophilus influenzae type b occur worldwide, detailed epidemiologic data are available in but a few countries. The public health impact of morbidity, mortality, and serious sequelae from disease caused by H influenzae type b has stimulated the search for control strategies. In the United States now, active immunoprophylaxis is largely favored over treatment of prophylaxis with antibiotics. This preference stems from three major observations: that high mortality and morbidity persist despite the availability of potent antimicrobial agents, that antibiotic-resistant strains of H influenzae type b have emerged, and that implementation of antimicrobial prophylaxis on a large scale has been unsatisfactory. Moreover, universal vaccination has been projected as offering a higher economic benefit than other control strategies. A matter of more proximate importance, however, is the search for H influenzae type b vaccines that will confer protection to all age groups, including infants younger than 18 months of age and subpopulations specifically at risk for invasive disease caused by H influenzae type b. Haemophilus b conjugate vaccine (meningococcal protein conjugate), PedvaxHIB (PRP-OMPC), is a conjugate H influenzae type b vaccine developed at Merck Sharp & Dohme Research Laboratories that now is undergoing extensive clinical evaluation to assess its prospects for disease control when first administered in early infancy. This is an interim report of results obtained in studies conducted in diverse locations throughout the United States.

Effects of three H2 antagonists on the isolated perfused rat liver. Correlation of bile flow changes with potential for causing hepatic disease in patients.

The adverse effects of oxmetidine, an H2 blocking agent which has been shown to produce hepatic injury in 1-4% of patients, on an in vitro model were compared with those of cimetidine and ranitidine which have led to only rare instances of hepatic injury. Bile flow was measured in the isolated perfused rat liver (Wistar rats), comparing the effects of each of the three drugs with control perfusions. Oxmetidine in concentrations of 3 X 10(-3) M or greater led to a decrease in bile flow within 15 min and, at a concentration of 5 X 10(-3) M, to complete cessation of flow within 5 min. Lower concentrations (5 X 10(-4) M) led to a marked choleresis. Ranitidine and cimetidine in concentrations up to 5 X 10(-3) M produced no decrease in bile flow. Ranitidine, however, led to a choleresis at a concentration of 5 X 10(-3) M. The positive correlation between in vivo and in vitro toxicity supports the view that in vitro testing may prove to be of use in predicting the hepatotoxic potential of a drug.

Long-term clinical and hemodynamic evaluation of the Ionescu-Schiley pericardial xenograft and the Braunwald-Cutter and Björk-Shiley prostheses in the mitral position.

Single mitral valve replacement was undertaken in 220 patients between March, 1971, and October, 1977. Bjork-Shiley prostheses (BS) were inserted in 42 patients, Braunwald-Cutter prostheses (BC) in 52, and Ionescu-Shiley pericardial xenografts (PX) in 126. No attempt was made at randomization. The actuarial survival rate was 81.9 +/- 12.8 percent at 7 years for patients with BS prostheses, 41.7 +/- 22.9 percent at 6 years for patients with BC prostheses, and 89.0 +/- 9.3 percent for patients with PX valves 7 years following valve replacement. Of the late deaths in patients with BC prostheses, 62.5 percent were valve related. The incidence of thromboembolism was 4.7, 1.8, and 1.5 episodes per 100 patient-years in the BS, BC, and PX groups, respectively. Long-term anticoagulation was used only in patients with BS and BC prostheses. Late postoperative hemodynamic studies were performed in six patients each with BS and BC prostheses and in 29 patients with PX valves. The mean diastolic gradients at rest were 6.2, 8.3, and 6.4 mm. Hg in the respective groups. The corresponding figures for calculated valve area were 1.8, 1.6, and 2.0 sq. cm. There was no statistically significant difference between the data recorded from the three groups of patients except for the survival rate of the BC prosthesis and the PX valve. The BS prosthesis and the PX valve have similar durability and hemodynamic performance for an almost identical duration of follow-up. Because of the improved quality of life and reduced morbidity without anticoagulants, we are using the PX valve exclusively for heart valve replacement.

Safety and immunogenicity of a Haemophilus influenzae type b conjugate vaccine in a high risk American Indian population.

The safety and immunogenicity of a Haemophilus influenzae type b polysaccharide conjugate vaccine linked to the outer membrane protein complex of Neisseria meningitidis (Hib-OMP) were evaluated among Apache and Navajo infants and children. One dose of the Hib-OMP was given to 42 children who were from 12 and 60 months of age. Ninety-two infants 6 to 8 weeks old were given one dose of Hib-OMP at the time of enrollment. A subsequent dose of the vaccine was given 2 months later and a third dose was offered between 12 and 15 months of age. All of the 12- to 60-month-old children achieved a protective antibody concentration (greater than 1 microgram/ml) 1 month postvaccination. Among the 6- to 8-week-old infants only 11% of the Apaches and 8% of Navajos had a protective anti-PRP antibody concentration prevaccination. One month post vaccination 68% of the Apaches and 69% of the Navajos had protective anti-PRP antibody concentrations. One month after the second immunization 67% of the Apaches and 75% of Navajos had protective anti-PRP concentrations. Among the infants that received the third (booster) immunization (N = 28) 74% had protective anti-PRP antibody titers just before the booster immunization. One month after the booster immunization all of the infants had protective concentrations of anti-PRP antibody. We conclude that the Hib-OMP is safe and highly immunogenic among Apache and Navajo infants and children.

Safety and immunogenicity of Haemophilus influenzae type B-Neisseria meningitidis group B outer membrane protein complex conjugate vaccine mixed in the syringe with diphtheria-tetanus-pertussis vaccine in young Gambian infants.

To ensure compliance and to reduce costs it is important, especially in less developed countries, that programs of child immunization should require as few clinic attendances and as few injections as possible. Therefore we have investigated whether a Haemophilus influenzae type b conjugate vaccine could be given safely and effectively with diphtheria-tetanus-pertussis vaccine (DTP). One hundred twenty-six Gambian infants were given both polyribosylribitol phosphate (PRP)-outer membrane protein complex (PedvaxHIB) and DTP on the same day at 8, 12 and 16 weeks of age; 60 were given the vaccines mixed in the syringe and 66 were given the vaccines separately. To minimize the injection volume the dose of PRP-OMPC used in both groups was 7.5 micrograms, which is half the usual dose. There were no significant differences in anti-PRP antibody titers between the groups after 1, 2 or 3 doses. The geometric mean titers of antibody for the two groups combined were 0.29 micrograms/ml 1 month after the first dose, 1.03 micrograms/ml after the second dose and 1.11 micrograms/ml after the third dose. Concentrations of antibodies to diphtheria, tetanus and pertussis 1 month after the third dose were not significantly different between the two groups. Systemic side effects were reported with equal frequency in the two groups and were similar to those reported elsewhere for DTP. Tenderness at the injection site was more common where the combined injection (0.75 ml) had been given than where DTP alone (0.5 ml) had been given. The main drawback to the use of these 2 vaccines together is the complexity of the mixing procedure used in this clinical trial.

Complications following esophageal surgery.

Chronologically, complications can be classified as intraoperative, early, and late. The authors analyze complications according to this classification on the basis of more than 400 esophageal operations and related literary data. As regards intraoperative complications, they deal only with those occurring at transhiatal esophagectomy (e.g., tracheal tear, bleeding, pneumothorax, laryngeal nerve injury). Among the early complications, they survey the incidence of transplant necrosis and related mortality, further sequelae ensuing from subacute ischemia of the replaced organ and analyze in detail the questions which arise regarding anastomotic leakage. Firstly, they deal with those causative factors that influence the frequency of anastomotic insufficiency, such as the technical "know-how" of anastomosis making (e.g., one layer vs two layers; stapling or manual suture; interrupted or running suture), the way of replacement using whole stomach or tube-stomach and the consequences originating from the route of replacement (e.g., anterior or posterior mediastinal route). Incidence and management of chylothorax are also dealt with. While dealing with late complications, the authors give a detailed comment on anastomotic strictures and also other factors facilitating the development of late dysphagia, such as peptic stricture and tumor of the organ remnant. Finally, some cases successfully treated by surgery are presented (skin-tube formation in cases following transplant necrosis; abolition of a pharyngogastric anastomosis stricture using a free jejunal transplant and surgical solution of an anastomotic stricture from median sternotomy approach).

Swim stress selectively alters the specific binding of a benzodiazepine antagonist in mice.

The ability of flurazepam to antagonize the electrical precipitation of tonic hindlimb extension is reduced 24 h after mice are forced to swim for 10 min in cold water (6 degrees C). Presumably, this reduction in flurazepam's antiseizure efficacy reflects an environmental stress-induced modification of the GABAA receptor complex. The current study employed a variety of complementary in vitro approaches to characterize the delayed effects of cold-water swim stress on binding parameters of the GABAA receptor complex that may be associated with flurazepam's reduced antiseizure efficacy. The specific binding of [3H]flunitrazepam and the potentiation of this binding by chloride ions did not change after stress in the cerebral cortex, hippocampus, and cerebellum. Moreover, swim stress did not alter the ability of GABA to inhibit the binding of [35S]t-butylbicyclophosphorothionate (TBPS), a ligand that is a specific biochemical marker of the GABA-associated chloride ionophore, to crude membranes prepared from the cerebral cortex and cerebellum. Swim stress was associated with alterations of the specific binding of [3H]Ro 15-1788, a benzodiazepine receptor antagonist, to crude hippocampal and cerebellar membranes. The results are considered in the context of new insights derived from molecular cloning studies of the GABAA receptor complex.

MK-801 alters the GABAA receptor complex and potentiates flurazepam's antiseizure efficacy.

MK-801 is an uncompetitive allosteric antagonist that interferes with glutamate-gated calcium ion conductance through the NMDA receptor-associated ionophore. In an outbred strain of mouse, MK-801 elicits episodes of explosive "popping" behaviors that may serve as a preclinical screening paradigm for novel antipsychotic medications. This investigation examined the effects of MK-801, at doses associated with the elicitation of popping, on the GABAA receptor complex in cerebral cortex, and flurazepam's ability to antagonize electrically precipitated seizures. Twenty four hours after MK-801 administration, there was an increased density of the radiolabeled antagonist-preferring conformation of the central benzodiazepine binding site and a potentiation of flurazepam's antiseizure efficacy. The data show that interference with NMDA receptor-mediated calcium ion conductance is associated with a relatively selective change in the GABAA receptor complex in cerebral cortex, and has functional behavioral consequences. Moreover, the data provide additional evidence for a delicate balance between GABAergic and glutamatergic transmission. Disturbance of this balance can have behavioral consequences for the animal.

Reduction of flurazepam's antiseizure efficacy persists after stress.

Twenty-four hours after mice were forced to swim for up to 10 min in cold (6 degrees C) water, the ability of flurazepam to antagonize the electrical precipitation of seizures was reduced. This stress-induced reduction in flurazepam's antiseizure efficacy persisted for at least 72 h; but was absent 1 week after the single session of swim stress. The data may be relevant to stress-related psychiatric disorders and suggest that the therapeutic efficacy of benzodiazepines may be altered after a severe stress.

Effects of milacemide, a glycine prodrug, on ethanol's antiseizure efficacy.

A variety of in vitro data suggest that ethanol interferes with N-methyl-D-aspartate (NMDA)-stimulated calcium ion conductance. This effect occurs at ethanol concentrations in blood associated with acute intoxication in the nontolerant human (less than 50 mM) and may involve its selective action at the strychnine-insensitive glycine binding site on the NMDA receptor complex. Moreover, there are in vitro data showing that glycinergic interventions can attenuate ethanol's inhibitory actions on NMDA-mediated transmission. The relevance of these in vitro findings to the intact animal was tested in an incremental electroconvulsive shock (IECS) paradigm using milacemide, a lipophilic prodrug of glycine. In this paradigm, the influence of milacemide on ethanol's ability to antagonize the electrical precipitation of seizures was tested. Doses of 3.2 and 32.0 mg/kg did not change ethanol's antiseizure efficacy, whereas 320.0 mg/kg potentiated ethanol's antiseizure efficacy. The mechanism of potentiation of ethanol's antiseizure efficacy by milacemide is unknown. Potentiation could result from stimulation of chloride ion conductance in the brainstem by glycine liberated from the lipophilic prodrug and acting at the strychnine-sensitive site. Alternatively, unmetabolized milacemide, which accumulates at the highest administered dose, may antagonize NMDA-mediated neural transmission. The latter explanation would be consistent with a role for receptor-gated calcium ion conductance in the mediation of ethanol's actions.

Ruptured aneurysms of the sinus of Valsalva.

From 1969 to 1989, 15 patients with an aneurysm of the sinus of Valsalva underwent operative correction. This represents 0.23% of 6515 cardiac operations with cardiopulmonary bypass during that time. There were 8 males and 7 females ranging in age from 15 to 54 years (mean 35.8 years). Symptoms of congestive heart failure, fatigue and palpitation were common. All patients underwent cardiac catheterization including aortography. Associated lesions included aortic valve regurgitation in 6 patients and a ventricular septal defect in 3 patients. The following connections occurred: right coronary sinus to right ventricle (8 patients), right coronary sinus to both right atrium and right ventricle (1 patient), and noncoronary sinus to right atrium (6 patients). The aneurysm was repaired via aortotomy or through the chamber into which it emptied. The aortic valve was replaced in 2 patients. There were no early or late postoperative deaths. Fourteen patients were in NYHA functional class I at late follow-up (range 0.5 to 20.5 years, mean 8.7 years). There have been no recurrences. Our experience supports the concept that early surgical intervention in patients with ruptured aneurysms of the sinus of Valsalva is justified.

Immunosurgical approach to the treatment of malignant melanoma using 2,4-dinitrochlorobenzene (DNCB).

Non-specific local immunotherapy using 2,4-dinitrochlorobenzene (DNCB) was combined with additional excision of the primary melanoma. The treatment was completed by elective nodal dissection in cases of high risk invasive lesions. DNCB was also given in cases with advanced disease for the control of cutaneous lesions and disseminated metastases, respectively. Histological changes of regressed skin nodules and ways of DNCB administration are described. Comparison between surgery alone and the immunosurgical treatment was considered inappropriate at the present time due to limited number of cases.

Lymphonodal response to sensitization with 2,4-dinitrochlorobenzene (DNCB) in laboratory rats.

The authors investigated the lymphonodal response to peripherally administered 2,4-dinitrochlorobenzene (DNCB). DNCB is known as a strong irritant binding to membrane proteins of the Langerhans cells of the skin. The conjugate is a potent neoantigen able to induce local tumor-destruction and raise cellular immune defence. White laboratory rats were used for the experiments. Their popliteal lymph nodes were investigated after sensitization with DNCB and i.c. injection of H3-thymidine and Patent Blue Violet at several intervals following the challenge with the hapten DNCB. Changes of weight of lymph nodes further uptake of H3-thymidine by the cells were investigated by autoradiography, while the content of H3-DNA indicating an increased DNA-metabolism due to blastic transformation of the small lymphocytes, was determined quantitatively by a liquid scintillation method. The data obtained speak for the usefulness of DNCB as an immunostimulant, comparable to BCG but of less toxicity.

Successful repair of left ventricular aneurysm due to blunt trauma. A case report.

The authors report the successful surgical treatment of their patient with posttraumatic aneurysm of the left ventricle. On the basis of the data reported in the literature and on their own experience, the authors consider this lesion absolute indication for surgery.

Right aortic arch with contralateral congenital subclavian steal syndrome.

Three cases of right aortic arch associated with contralateral congenital subclavian steal syndrome are presented. Diagnosis may be made if special attention is given to the blood pressures and amplitude of pulses in both arms. Retrograde aortography is necessary to establish a definitive diagnosis. If symptoms are present in the adolescent, a bypass graft procedure should be performed.

Bilateral congenital coronary artery-pulmonary artery fistulas. Report of two cases and review of the literature.

Congenital coronary arteriovenous fistulas involving both coronary arteries are rare. Two cases are presented where the origin and termination of the fistulous communication have been visualized by selective coronary angiography. Both patients underwent successful surgical treatment. Our experience and the clinical features of 12 previously reported cases treated surgically are discussed.

A unique malfunction of Cross-Jones mitral valve prosthesis.

This case report is concern with the death of a patient 20 months following mitral valve replacement. The disc of a Cross-Jones prosthesis escaped into the left atrium causing severe mitral insufficiency. Disc variance represents a potentially lethal complication and patients with disc valve prostheses should be examined frequently. When signs and symptoms of mechanical malfunction develop, the valve prosthesis should be replaced immediately to prevent sudden death.