Hypothyroidism as the cause of atrioventricular block in an elderly patient.

Syncope is a common problem in the older patient. Sometimes syncope is caused by extreme bradycardia secondary to atrioventricular (AV) block. We describe a case in which a 90-year-old woman presented with complete AV block due to severe hypothyroidism. After suppletion with levothyroxine, AV conduction was restored. (Neth Heart J 2008;16:57-9.).

Spontaneous coronary artery dissection: current insights and therapy.

Spontaneous coronary artery dissection (SCAD) is a very rare cause of acute coronary syndromes in young otherwise healthy patients with a striking predilection for the female gender. The pathological mechanism has not been fully clarified yet. However, several diseases and conditions have been associated with SCAD, such as atherosclerosis, connective tissue disorders and the peripartum episode. In this paper we present a review of the literature, discussing the possible mechanisms for SCAD, therapeutic options and prognosis. The review is illustrated with two SCAD patients who had a recurrence of a spontaneous dissection in another artery within a few days after the initial event. Because of the susceptibility to recurrent spontaneous dissections we propose at least one week of observation in hospital. Further, we will elaborate on the possible conservative and invasive treatment strategies in the acute phase of SCAD. Primary percutaneous coronary intervention remains the reperfusion strategy of choice; however, in small and medium-sized arteries with normalised flow conservative treatment is defendable. In addition, after the acute phase evaluation of possible underlying diseases is necessary, because it affects further treatment. (Neth Heart J 2008;16:344-9.).

A delta F508 mutation in mouse cystic fibrosis transmembrane conductance regulator results in a temperature-sensitive processing defect in vivo.

The most prevalent mutation (delta F508) in cystic fibrosis patients inhibits maturation and transfer to the plasma membrane of the mutant cystic fibrosis transmembrane conductance regulator (CFTR). We have analyzed the properties of a delta F508 CFTR mouse model, which we described recently. We show that the mRNA levels of mutant CFTR are normal in all tissues examined. Therefore the reduced mRNA levels reported in two similar models may be related to their intronic transcription units. Maturation of mutant CFTR was greatly reduced in freshly excised oviduct, compared with normal. Accumulation of mutant CFTR antigen in the apical region of jejunum crypt enterocytes was not observed, in contrast to normal mice. In cultured gallbladder epithelial cells from delta F508 mice, CFTR chloride channel activity could be detected at only two percent of the normal frequency. However, in mutant cells that were grown at reduced temperature the channel frequency increased to over sixteen percent of the normal level at that temperature. The biophysical characteristics of the mutant channel were not significantly different from normal. In homozygous delta F508 mice we did not observe a significant effect of genetic background on the level of residual chloride channel activity, as determined by the size of the forskolin response in Ussing chamber experiments. Our data show that like its human homologue, mouse delta F508-CFTR is a temperature sensitive processing mutant. The delta F508 mouse is therefore a valid in vivo model of human delta F508-CFTR. It may help us to elucidate the processing pathways of complex membrane proteins. Moreover, it may facilitate the discovery of new approaches towards therapy of cystic fibrosis.

Prevalence and clinical significance of an elevated cardiac troponin I in patients presenting to the Emergency Department without chest pain.

BACKGROUND: Cardiac troponins are currently measured in patients presenting with chest pain. Little is known about routinely measured cardiac troponins in patients presenting without chest pain. The aim of this study was to determine the prevalence and clinical significance of an elevated cardiac troponin I (cTnI) in patients presenting to the Emergency Department without chest pain. METHODS: During a 6-month period, we routinely measured cTnI in all patients presenting to the internist, neurologist, or lung specialist for reasons other than chest pain. We followed patients with an elevated cTnI for 1 year and determined mortality and incidence of non-fatal myocardial infarction, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). RESULTS: cTnI was elevated in 41 out of 1130 patients (3.6%). Patients with an elevated cTnI were older (78 vs. 62 years) and more often admitted to the hospital (95% vs. 78%) than those with a normal cTnI. Twenty-six patients (63%) with an elevated cTnI died within 1 year. Approximately 50% of these deaths were cardiac-related. Two patients (4.9%) suffered a non-fatal myocardial infarction, while no patient underwent PCI or CABG during follow-up. CONCLUSION: Routinely measured cTnI is seldom elevated in a general population of patients presenting to the Emergency Department without chest pain. Patients with an elevated cTnI are, on the average, 16 years older than those with a normal level. An elevated cTnI is clearly associated with an unfavorable outcome.

Role of glutathione in the in vitro synergism between 4-hydroperoxy-cyclophosphamide and cisplatin in leukemia cell lines.

To explain the sequence-dependent in vitro cytotoxic synergism between 4-hydroperoxycyclophosphamide (4-HC) and cisplatin in the K-562 human leukemia cell line, we have hypothesized that 4-HC decreases cellular glutathione (GSH) levels and that the resulting diminution of the cellular protective effect of GSH leads to the increased cytotoxicity of cisplatin. Exposure of K-562 cells to 4-HC resulted in a concentration- and time-dependent depletion of cellular GSH. To determine the effect of modulation of GSH levels on the toxicity of cisplatin, K-562 cells were exposed to buthionine sulfoximine (BSO) and/or GSH ethyl esters. Depletion of GSH to approximately 10% of control values by BSO potentiated the cytotoxicity of cisplatin, while rapid replenishment of GSH to within normal levels by GSH esters abolished the potentiation of BSO. Doubling cellular GSH by incubation with GSH esters protected against cisplatin cytotoxicity. Of importance, pretreatment of K-562 cells with BSO, in addition to increasing the cytotoxicity of 4-HC and cisplatin, abolished the synergism between the two drugs. The working hypothesis was also tested in two other cell lines in which the cytotoxic synergism between 4-HC and cisplatin was exhibited: the Raji cell line, a human lymphoblastic cell line, and the L1210-CPA cell line, a subclone of the murine L1210 leukemia with resistance to 4-HC. GSH levels in these two cell lines were not altered by incubation with concentrations of 4-HC at which the synergism was observed. In conclusion, the data for the K-562 cell line, indicating that (a) 4-HC depletes cellular GSH levels, (b) the lowering of cellular GSH levels enhances the toxicity of cisplatin, and (c) intact GSH stores are required for the synergism, strongly support the postulate that the cytotoxic synergism between 4-HC and cisplatin is modulated by GSH levels in this cell line. However, the lack of 4-HC-mediated depletion of GSH at concentrations of 4-HC resulting in cytotoxic synergism in the Raji and L1210-CPA cell line indicates that mechanisms other than modulation of GSH levels by 4-HC are responsible for the synergism in these cells.

Successful management of postinfarction ventricular septal rupture.

Ventricular septal rupture is a rare but devastating complication of acute myocardial infarction. Especially in patients with cardiogenic shock, right ventricular dysfunction or an inferior infarct mortality is very high. We present a case in which an 83-year-old patient survived rupture of the ventricular septum complicating an inferior myocardial infarction. Unlike most patients his haemodynamic status did not deteriorate and delayed elective surgical repair was carried out successfully.

Coronary artery dissection following blunt chest trauma: a case report.

Coronary artery dissection following blunt chest trauma is rare. We report the case of a 43-year-old woman who was admitted with a subacute inferior myocardial infarction due to dissection of the right coronary artery. Ten days earlier, she had sustained a minimal chest trauma. The literature is reviewed and management is discussed.

Steroidal silicon side-chain analogues as potential antifertility agents.

A number of silicon-substituted analogues of ethynylestradiol that exhibit modified and enhanced biological activities have been synthesized. Particularly noteworthy are a group of [(trialkylsilyl)ethynyl]estradiol analogues that exhibit high antifertility potency and markedly reduced estrogenic activity. The best compounds synthesized are 17 alpha-[(triethylsilyl)ethynyl]estradiol (5) and 17 alpha-[(tert-butyldimethylsilyl)ethynyl]estradiol (33), which show a separation of antifertility from estrogenic activity in the rat. The results of structure-activity studies indicate a good correlation between the observed biological activities and the calculated van der Waals volumes of the three variable silicon substituents.

Analogues of [(triethylsilyl)ethynyl]estradiol as potential antifertility agents.

Various 17 alpha-ethynylsteroids were prepared and derivatized as the corresponding triethylsilyl compounds 2-35, which were examined for a ratio of antifertility to estrogenic activity that would be more beneficial than that of the presently used agent. Among the triethylsilyl compounds evaluated, only 23 displayed this desired ratio, although two other compounds without the triethylsilyl moiety, 18 and 26, shared similar characteristics.

PIP: In a previous study of ethynyl estradiol derivatives by the authors, it was found that even a small presence of silicon was beneficial. The silyl derivatives showed a reduction in estrogenic activity along with a retention of the level of oral antifertility activity. In relation to endocrine disorders and the undesired side effects of prescribed contraceptives, the finding is positive. In the present study, the effects of structural changes in the A, B, C, and D rings of the ethynyl estradiol steroidal nucleus were examined in conjunction with C-21 triethylsilyl moiety. The general method of Ethynylation and Triethylsilylation are described in detail and the oral antifertility and oral estrogenic potencies of the compounds are described and compared. Of the various triethylsilyl compounds examined for an antifertility to estrogenic activity ration that would be more beneficial than that of a present agent, only 23 manifested the desired ratio. Compound 18, which was 66% as effective as ethynyl estradiol as an antifertility agent, had 0.1% of the estrogenic activity of ethynyl estradiol and was singled out for the greatest separation between antifertility activity and estrogenic activity. 2 groups of rats, 1 immature females and the other adult, female, cycling rats were tested for oral estrogenic activity and oral antifertility activity, respectively.

17-Desoxy estrogen analogues.

A series of 17-substituted, 17-desoxyestratrienes have been synthesized and tested as potential postcoital antifertility agents. Estrogen-relative binding affinities were determined, in vivo assays for estrogenic and postcoital antifertility activity were conducted in rats, and selected candidate compounds were further tested for estrogenic activity in monkeys. In the rat, the 17-desoxyestratriene derivatives 8a, 8b, and 30 have shown low estrogenic activity while retaining potent antifertility activity. Structural modifications at the outset included a variety of 17-substituents and an omission of the 17-oxygen functionality, which was previously thought to be necessary for potent activity. The 17 beta-ethyl side chain exhibited the greatest antifertility activity with the largest separation ratio to estrogenicity. Nuclear modification of 17-desoxyethylestrane derivatives at positions 7 and 11 further increased the desired separation of activity, with the 11-hydroxy moiety enhancing separation more than other features.

11 beta-nitrate estrane analogues: potent estrogens.

Various estrane derivatives 1 reacted with cerium ammonium nitrate (CAN) selectively and efficiently to provide 9 alpha,11 beta-defunctionalized derivatives 2, which were subsequently deoxygenated at C-9 with triethylsilane/boron trifluoride etherate to the desired target 11 beta-nitratoestranes 3a, 3b, and 5. When examined for estrogenic and postcoital antifertility activity, 11 beta-nitrates 2c, 2d, and 3b most notably displayed more potent oral activity than did ethynylestradiol.

Determination of the mean normal prothrombin time for assessment of international normalized ratios. Usefulness of lyophilized plasma.

To report a Prothrombin Time (PT) as International Normalized Ratio in controlling oral anticoagulant therapy, the Mean Normal PT (MNPT) is required. To correct for methodological differences in performing the PT test, each laboratory should determine its own MNPT for each batch of reagent using fresh blood samples from a large number of normal individuals. This would be a laborious procedure. Two models for simplified assessment of MNPT were investigated by two laboratories in a collaborative study. According to the models, the MNPT of a new batch of reagent is calculated, using the PT of a lyophilized control plasma measured with the new batch and a reference batch, as well as the MNPT of the reference batch obtained with fresh samples. Experimental results were obtained with 19 batches of bovine thromboplastin, 4 lyophilized normal control plasmas and fresh blood samples of 40 normal individuals. The PTs of the 4 lyophilized normal control plasmas were not identical to the MNPT of the fresh normal samples and also different from each other. Therefore, the uncorrected PTs of these control plasmas cannot be used as MNPT. In general, there was good agreement between measured and calculated MNPT, although some control plasmas gave better results than others. There were no significant differences between the results obtained by both calculation models.

A Multi-centre study to evaluate method dependency of the international sensitivity index of bovine thromboplastin.

In The Netherlands, a particular coagulometer method for prothrombin time (PT) determination with reduced sample and reagent volumes is used by 62% of the laboratories controlling oral anticoagulant therapy. This "micro-method" has been calibrated against the manual tilt-tube technique for PT determination by six Dutch laboratories. Each laboratory tested 20 fresh normal blood samples and 60 fresh patient blood samples using both methods with the same batch of bovine thromboplastin reagent, according to a detailed protocol. Both methods were comparable as to their precision, but PTs measured by the micro-method were significantly prolonged (p less than 0.001, Student's t-test) as compared to the manual method. This effect is stronger for samples of normal subjects than for patients' samples. It was assumed that the International Sensitivity Index (ISI) of the bovine thromboplastin for the manual method was 1.00 in each laboratory. The ISI-values of the bovine thromboplastin for the micro-method determined by the six laboratories ranged from 1.00 to 1.07 (mean 1.03, SD 0.03). Our results indicate that any other laboratory, using this thromboplastin and the micro-method, should obtain accurate assessment of the International Normalized Ratio from their own mean normal PT and an ISI which is 3% higher than the ISI supplied by the thromboplastin manufacturer for the manual tilt-tube method.

Learned aversions to copulatory behaviors in male rats.

When male rats received an injection of lithium chloride immediately after an encounter with an estrous female, the vigor of subsequent copulatory responding was initially unaffected. After 5 to 10 such pairings, however, male rats displayed an aversion to copulatory behaviors; they ceased to copulate entirely. These aversions persisted when the rats were tested in a novel environment and extinguished after four nonreinforced trials. This multiple-trial adaptation of the conditioned taste aversion paradigm provides a new approach to the aversive control of sexual behavior.

Differential effects of yohimbine and naloxone on copulatory behaviors of male rats.

Prior research has demonstrated that both yohimbine, an alpha2-adrenergic antagonist, and naloxone, an opiate antagonist, facilitate components of copulatory behaviors in nonstressed male rats. In the present experiments, we demonstrate that these drugs differentially affect copulatory behaviors when the behavioral testing situation contained an aversive element. Male rats received an injection of lithium chloride (0.3 M, 20 ml/kg, ip) immediately after each encounter with an estrous female. Consequently, male copulatory behaviors gradually declined during successive test sessions. These male rats also received ip injections of either yohimbine (2 mg/kg/ml), naloxone (4 mg/kg/ml), or isotonic saline 20 min prior to each copulation test. Yohimbine-treated rats were more likely to copulate than control rats during both acquisition and extinction of lithium chloride-induced associative inhibition of copulatory behavior. Conversely, naloxone-treated rats were less likely to copulate than control rats during both acquisition and extinction. These data are consistent with the hypothesis that yohimbine increases sexual motivation in the male rat and limit the generality of the excitatory effects of naloxone on copulatory behaviors.

Copulation-illness associations in male rats: lithium chloride dose and delay manipulations.

Male rats that receive an injection of lithium chloride (LiCl) after each pairing with an estrous female gradually decrease their copulatory behaviors. In the present experiments we demonstrated that a 6.0 mEq/kg (0.3 M, 20 ml/kg) dose of LiCl injected after trials spaced twice weekly at 3-4-day intervals induced more rapid acquisition of copulation-illness associations than a 3.0 mEq/kg (0.15 M, 20 ml/kg) dose. Contingent 0.3 M saline or noncontingent 0.3 M LiCl injections did not affect copulatory behaviors. The location of the male rat (home cage or test chamber) during a portion of the aversive state induced by LiCl did not influence rate of acquisition. Copulation-illness associations, once established, were retained over a 60-day interval. Comparable decrements in copulatory behaviors were evident when LiCl was injected at 1-, 5-, or 15-min intervals after pairings with estrous females when the males were detained in the test chambers during the delay intervals; decrements were not observed when the interval was increased to 30 or 60 min. An electric shock analog to the aversive state induced by LiCl did not induce decrements in copulatory behaviors. It was suggested that odor-illness associations may, in part, account for the decrements in copulatory behaviors in this paradigm.

Multicentre evaluation of the Thrombotest International Sensitivity Index used with a steel ball coagulometer.

AIM: To compare the International Sensitivity Index (ISI) of the Thrombotest reagent used with a steel ball coagulometer (KC) to the ISI of the same reagent used with the manual (tilt tube) technique. METHODS: The study was carried out by eight laboratories using their own KC instrument and method of testing. All laboratories used the same batch of Thrombotest to determine the clotting times of fresh blood samples from 20 local healthy volunteers and 60 patients on long term oral anticoagulant therapy. KC clotting times were plotted against manual clotting times on double logarithmic scales. Orthogonal regression lines were calculated to assess the ISI. RESULTS: In two laboratories the ISI of the KC method was lower than that of the manual method; these differences, however, were 2% or less. In the other laboratories no clinically important differences were observed between ISI values obtained. However, the clotting times determined with the KC methods were shorter than the manual values. CONCLUSIONS: The ISI of Thrombotest determined with the KC methods was very similar to the manual value. Therefore, use of the ISI value supplied by the manufacturer without adjustment is justified. The mean normal prothrombin time, however, must be determined locally.

In vitro synergism of 4-hydroperoxycyclophosphamide and cisplatin: relevance for bone marrow purging.

Autologous bone marrow transplantation with 4-hydroperoxycyclophosphamide (4-HC)-purged bone marrow gives long-term remission in almost half of relapsed acute nonlymphocytic leukemia and non-Hodgkin's lymphoma patients, but relapse of disease is the main cause of failure, suggesting ineffective purging in some cases. Cisplatin (CP) has activity against a variety of human tumors and is not commonly used for initial therapy of leukemia and lymphoma. Using established human leukemia cell lines, combinations of 4-HC and CP were investigated as a potential regimen for improving the ex vivo removal of leukemia cells from bone marrow. The cell lines (K-562 and Raji) were incubated for 1 (4-HC) or 4 h (CP), washed, and assayed for inhibition of colony formation in semisolid media. In both cell lines, CP (4h) was more potent than 4-HC (1 h). Combinations of the drugs in various molar ratios were studied after the cells were sequentially incubated with 4-HC and CP. The effects of the drugs were analyzed using the multiple drug-effect analysis of Chou and Talalay. Analysis of data on in vitro inhibition of colony formation suggested that all combinations studied were synergistic in both cell lines, with the greatest synergism being found in the Raji cell line. In addition, for K-562 cells we could detect at least a 4.6 log reduction in cloning with the CP:4-HC combination (1:10 molar ratio). We conclude that CP is a potential candidate in drug combinations for ex vivo bone marrow purging because of its high potency against human leukemia cell lines, its synergistic activity in combination with 4-HC, and its ability to reduce a high tumor burden when combined with 4-HC.

Cellular glutathione as a protective agent against 4-hydroperoxycyclophosphamide cytotoxicity in K-562 cells.

Exposure of cells of the K-562 erythroleukemia cell line to 4-hydroperoxycyclophosphamide (4-HC), an analog of activated cyclophosphamide, causes a concentration-dependent inhibition of in vitro colony formation by these cells. For investigation of the role of glutathione (GSH) in the metabolism of 4-HC, GSH levels of K-562 cells were modulated by exposing the cells to buthionine sulfoximine (BSO), a specific inhibitor of GSH synthesis, and/or to GSH ethyl esters. Both the mono- and diethyl esters of GSH were synthesized in our laboratories and their identities were determined by chromatographic methods and fast-atom-bombardment mass spectrometry. An HPLC method including electrochemical detection used for thiol determination was applied for the measurement of GSH esters. Incubation of the cells with BSO depleted GSH levels to approximately 11% of control values and potentiated the cytotoxicity of 4-HC. By contrast, exposure to GSH esters approximately doubled GSH levels and protected the cells against the toxicity of 4-HC. Moreover, when cellular GSH levels were first depleted by BSO exposure and then replenished by incubation with GSH esters, the BSO-associated potentiation of 4-HC cytotoxicity was abolished. The work described herein extends the application of an HPLC method used for thiol determination to the measurement of GSH ethyl esters. In addition, it established that GSH acts as a competitive protecting agent against the in vitro toxicity of 4-HC in the K-562 cell line.

Synthesis and testing of 17a beta-hydroxy-7 alpha-methyl-D-homoestra-4,16-dien-3-one: a highly potent orally active androgen.

The title compound, 17a beta-hydroxy-7 alpha-methyl-D-homoestra-4,16-dien-3-one (3), was synthesized in five steps (17% overall yield) from 7 alpha-methylestrone methyl ether (5) and was found to possess oral androgenic activity, in excess of other known androgens, without using 17 alpha-alkyl substitution.